Support Group Registration and Waiver Form January 2025 to June 2025

MHA Support Group Registration Form & Waiver Form

Thank you for your interest in our support group(s). Please fill this quick registration form (your answers will be anonymous and confidential).
MHA Support Group Registration and Waiver Form

January 2025 to June 2025
Registration Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Group:
General Information
Name

First NameMiddle NameLast Name
Preferred Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth Date

MonthDayYear
Date
Ethnicity
Gender
Income
Preferred Pronouns
Residence Information
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information

In the event of an emergency, I gave MHA permission to contact: (include their phone number)
Primary Emergency | Contact Name

First NameLast Name
Primary Emergency | Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is your relationship with this person?
Is there anything else you would like us to know?
Does the Mental Health Association in Forsyth County have your permission to send information about the agency including newsletters, upcoming special events, speaker meetings, trainings, closings/delayed openings in the event of bad weather, etc.? (NOTE: E-mail notices are sent via Mail Chimp. No one else can see your email address.)
By checking the box labeled "yes, I agree" below, I hereby release the Mental Health Association in Forsyth County (MHA), its officers, directors and employees, contract personnel, sponsors, personnel or any parties connected with MHA support groups, from any and all liability which may arise out of or relate to my participation in MHA support groups and I hereby waive all claims against such person(s) in connection therewith. Further, I know that I need to abide by the support group guidelines and I understand that failure to comply may result in my being asked to leave the group.
Signature
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Mailed Thank You Note:
Note Date:

MonthDayYear
Date
Should be Empty:

MHA Support Group Registration Form & Waiver Form

MHA Support Group Registration and Waiver Form

General Information

Residence Information

Emergency Contact Information

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