Spunk Spring 2023 Series Intake Form

Spunk Spring 2023 Series Intake Form
Spunk! Spring 2023 Series

All information is kept confidential, and is only for intake purposes of Spunk! All information will be deleted from this form once the intake process has completed. For any further information, please email Vince Pacilli, Gay Men's Harm Reduction and Sexual Health Coordinator at: vpacilli@actoronto.org
Name (or Alias)*

First NameLast Name
Email*
example@example.com
Postal Code (Enter M4Y 1Y5 if you do not have a fixed address)*

Street Addrss

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date

This SPUNK series will be offered on the following dates:

Session 1: Wednesday March 22nd 5:30-8:30pm

Session 2: Wednesday March 29th 5:30-8:30pm

Session 3: Wednesday April 5th 5:30-8:30pm

Session 4: Wednesday April 12th 5:30-8:30pm

Session 5: Wednesday April 19th 5:30-8:30pm

Session 6: Wednesday April 26th 5:30-8:30pm
Are you able to attend the SPUNK dates listed above?

YesYes, most of themNo
Please choose a time for a secondary 1-on-1 intake session with Vince over Zoom*
Should be Empty:

Spunk! Spring 2023 Series