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 – firstname.lastname@example.org. Website – www.alaafiaafrc.org.
Alaafia Digital Media Training Application Form for Sickle Cell Families.
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.
Are you living with Sickle Cell or a Sickle Cell Caregiver or Have you completed a Sickle Cell Transplant?
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Emergency Contact Name
Emergency Contact Email
Let us learn more about your interest and support in doing this type of work. We 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:
Web Design & Development
Social Media Management
Content Creation & Management
Proposal & Resume Writing
Digital Media Marketing
Virtual Customer Service
Describe any particular life circumstances that brought you here or interested you in this training:
Do you have a laptop or tablet or an internet for the training?
Do you have someone who can you reach out to for help in integrating what you have experienced during your session?
Tell us about your Sickle Cell History:
List of Sickle Cell Mediations and Treatments:
Please list any allergies that require regular treatment and medication:
Mental Health, Stress, Anxiety & Trauma History
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
Recent job loss
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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