Participant's Orientation/Contact Form

Participant's Orientation/Contact Form

This information will be shared with your facilitator
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Today's date*

MonthDayYear
Date
When would you like to start class?*

Immediately!I will contact Cynthia Buckley at Cynthia@uniquewomen.net when I am ready to start.Not at this time.
Preferred class day*
Your assigned facilitator is listed below. She will contact you before your next class. (Tuesday Online)

1-Jackie Palmer- Ada2- Ifeoma Anaya4- Joanna Saavedra5- Beverly McNearly- DeRavalliere9- Shikonya Cureton11- Alisa Allen13- Norka Jenkins21- Shirley Seals28- Leslie Jack29- Manda Norman30- Lisa Smith33- Xiomara Browne38- Sherri Dawkins
Your assigned facilitator is listed below. She will contact you before your next class. (Tuesday In Person)

3-Cynthia Buckley4- Joanna Saavedra15-Kendra Jefferson
Your assigned facilitator is listed below. She will contact you before your next class. (Friday Online)

5- Beverly McNearly- DeRavalliere20-Julie Gonzalez26- Deborah Yanez34- Alba Iaconi37- Patrina Murray
Facilitator's email
example@example.com
Should be Empty: