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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