Men of Valor-Registration

*You and your mentor must register separately. Please be sure to list each other on the registration form below so we can work with you together.

Who is your mentor or buddy for the Retreat?*

First NameLast Name

Do you feel safe with this buddy/mentor?*

Do you have any special dietary needs?*

YesNo

If so, please explain your dietary needs.

Do you have any physical limitations?*

YesNo

If so, please describe your physical limitations?

Are you currently receiving counseling or therapy?*

YesNo

If so, who is your counselor?

In the past have you been diagnosed with any mental health issues?*

YesNo

If so, how recent?

Are you currently taking medication for these issues?

YesNo

Have you been addicted to any substances or behaviors?*

YesNo

If so, are you in recovery and sober?

YesNo

In the past have you attempted suicide or harm to yourself or others?*

YesNo

If so, how recent?

Were you ever abused physically or sexually?*

YesNo

If so, how long ago?

What personal goals do you hope to accomplish on the Men of Valor Retreat?*

If there anything specific you want/need to do with your buddy/mentor this weekend?

Participant Questionnaire