Are You OK Sis?
2017 Application
The African American Women's Leadership and Wellness Mental Health Outreach Project
APPLICATION FOR PARTICIPATION
Thank you for your interest in the upcoming workshop series. Please answer the following questions to be considered for participation. All of your answers will be kept confidential. Please call us at 562-513-0886 with any questions.
Email address
Your answer
Name
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Phone Number
Your answer
Email
Your answer
Age
Marital Status
Your answer
Gender
Are you a care-giver or parent to children in the home?
Work status
Do you have reliable transportation?
What is your income?
Your answer
What is your education level?
Are you a veteran?
Are you homeless?
What would you like to learn from attending the mental health workshop, Are You Ok, Sis?
Your answer
What are your experiences with the mental health care system?
Your answer
If selected to attend, can you commit to attend two, 4 hour trainings?
What date(s) would you like to attend? Select all that apply:
Required
Do you need any special accommodations?
Do you have special dietary restrictions?
How did you hear about these trainings?
Your answer
Please provide any additional information you would like us to know.
Your answer
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