Alaafia African Family Resource Center
Alaafia is a Registered 501(c)(3). All donations are tax-deductible. Registered No 84-4761643. Phone- 414-432-3555 Email – info@alaafiaafrc.org Website – www.alaafiaafrc.org
Alaafia Digital Media Training Participant Application Form
We appreciate your cooperation in answering the questions in this form as fully as you can This information will be kept strictly confidential. Your personal information is collected for the purpose of supporting you properly and for administrative purposes. It will not be disclosed for other purposes without your consent.
Name:
First Name
Last Name
Date of Birth
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact Email
example@example.com
Let us learn more about your interest and support in doing this type of workWe would love to learn some more about you to allow us to better support you in this process. Please write a short response to each of the following questions. We invite you to give yourself a few moments to sit with the question and share from your heart.
Do you have previous work experience? Please share the broad details:
What Course(s) Training are you interested in:
Video Editing
Web Design & Development
Information Technology
Graphic Designs
Social Media Management
Content Creation & Management
Writing
Blogging/Vlogging
Copy Writing
Proposal & Resume Writing
Digital Media Marketing
Public Relations
Project Management
Virtual Customer Service
Customer Service
Personal Healthcare
Describe any particular life circumstances that brought you here or interested you in this training:
Do you have someone who can pick you up and be available to help you after your session?
Do you have someone who can you reach out to for help in integrating what you have experienced during your session?
Pre-existent Medical & Mental Health ConditionsPlease be honest in the section below, as it will not necessarily preclude you from working with us, it will simply involve clarifying which approaches might be best for you, or what work we need to do before a session. Dishonesty will put you and the facilitators at risk, and will not lay the proper groundwork for you to have a safe and energetically clear journey.
Please list any allergies that require regular treatment and medication:
Mental Health, Stress, Anxiety & Trauma History
Please list any current significant mental health issues:
Are you taking any prescription medication for psychological conditions? If yes, what kind and reason?
Please list any stimulant or recreational drug use. Type and frequency:
I have experienced the following:
Loss or death
Chronic illness
Relationship stress
Recent job loss
Abuse: Sexual/Mental/Physical/Emotional
Substance Abuse
Other
Journey Goals
Tell us about your strengths, hobbies, interests. What do you like to do for fun and relaxation?
Please describe your goals for this work:
Anything else you think we should know about you so we can provide you with the best support possible.
My signature below affirms that I have answered the above as truthfully and completely as possible: Signature
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