Stronger Women Virtual PreRegistration

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Are you a female?* This field is required.This program is currently for women only.

YESNO

5

Are you 18 and over?* This field is required.Must be 18 and over to participate in our Women's program. Teen programs is currently in development.

YESNO

6

Are you a survivor of Domestic Violence?* This field is required.Safely away from your abuser, not currently dating or living with him.

YESNO

7

Which class are you interested in attending?* This field is required.Choose one option.

In Person - TEXAS

In Person - USA

Virtual - USA

8

VIRTUAL CLASS - Do you have a secure space to attend this webinar?* This field is required.Must need headphones, laptop with camera on and a private room to secure a spot on our webinar class.

YES

NO

N/A

10

CURRENTLY OR RECENTLY: Is his behavior escalating, becoming more reckless, scary, or violent?* This field is required.

YESNO

11

CURRENTLY OR RECENTLY: Does he have a history of suicide attempts or has he threatened to kill you or any of your loved ones?* This field is required.

YESNO

12

CURRENTLY OR RECENTLY: Does he have weapons and has recently used them to threatened you or others?* This field is required.

YESNO

13

Do you need childcare to attend an IN PERSON class? TEXAS ONLY* This field is required.Please select all answers that apply.

No

YES

Children under 5 yrs old

Children 5-10 yrs old

Children over 10 yrs old

More than 2 children

N/A