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Welcome & Wellness Center Registration Form
Please complete this form and we will be reach out to confirm your registration and gather any additional information needed.
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* Indicates required question
Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
I am interested in participating in the following programs/classes:
*
Getting Ahead in a Just-Gettin-By World
Women's Peer Support and/or Mentoring
Men's Peer Support and/or Mentoring
Control the Fire: Anger Management Classes (DRMI) - Satisfies probation requirements
Reclaiming Freedom from Addictions and Substances Program (DRMI) - Satisfies probation requirements
Financial Literacy Workshops - by Synovus
GED Support and Tutoring
Other:
Required
Phone number
Your answer
Email
Your answer
How do you prefer to be contacted?
*
Phone call
Text
Email
Required
Gender
*
Female
Male
Other:
Zipcode
Your answer
Race and Ethnicity
Your answer
I am formerly incarcerated
*
Yes
No
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