Afya Sanaa Membership Form

Afya Sanaa Membership Application

Afya Sanaa is a healing center and community space where Minnesotans who identify as Black, African, African American, and ADOS can find the solace, safety and fellowship to start their journey to healing. Self expression, wellness, and community participation are the foundation and cornerstone of Afya Sanaa's mission to heal through art, knowledge, love & health. Become a member today to access all of Afya Sanaa's programs, workshops, classes, and healing services.
Name *

First Name Last Name
Preferred Name
Do you identify as Black, African, African American, ADOS?

YesNo
Mobile Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
example@example.com
Birthday

MonthDayYear
Date
Check all that apply to you:

I want to participate in Workshops and ClassesI want to participate in ProgramsI want to book sessions for Healing ServicesI want to help or volunteerI want to facilitate a class or workshopMy organization wants to partner w/ Afya SanaaOther
Personal Reference

First NameLast Name
Personal Reference Phone Number

Area CodePhone Number
Personal Reference Email
example@example.com
What is your occupation?
What is your activity level at your job?

None (seated all day)Moderate (light activity, walking)High (regular movement, lifting)
Tell us a little bit about yourself...
What are your goals for health and healing? What else would you like us to know about you?
What are your wellness goals?
Please share your social media links below:
Facebook
Instagram
Youtube
Today's Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Afya Sanaa Membership Application