UPDATE FORM BEFORE USE
Form Updated 08/29/23
Healing Circle Registration
Hey Mama, looking forward to seeing you during Brown Mamas' Healing Circles. Sessions will be held virtually via Zoom Complete this form in its entirety. These are drop-in sessions. Come to most sessions or come to all. We're excited to see you there. Thanks!
Here are the session dates from July to October 2023:
July 20th & 27th , Aug 10th & 17th, Sept 21st & 28th, Oct 19th & 26th
Email
*
example@example.com
Name
*
First Name
Last Name
What is your Facebook name? If none, type "N/A". We will use this for session reminder purposes
*
Cell Phone Number
*
Please enter a valid phone number.
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your best form of communication?
*
Cell phone/text
Email
Facebook
Other
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Demographics
Providing this information, helps us to know our audience in order to inform programming. Thanks!
Age Range
*
20-30
31-40
41-50
50+
Marital Status
*
Single
Married
Divorces
Other
Income Level
*
Less than 30k
30k-50k
50k-75k
75k +
Highest Level of Education
*
High school or equivalent
Technical or occupational certificate
Associate degree
Some college coursework completed
Bachelor’s degree
Master’s degree
Doctorate
Employment Status
*
Part Time
Full Time
Self-Employed
Unemployed
Other
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Just a few more things...
The Healing Circle is a safe space to be heard. Select the topics you're most interested... select all that apply.
*
Self-Care & Radical Self-Acceptance
The Principles of Productive Male/Female Alliances
African-Centered Parenting
Black Female Friendships
Other
Answers routed to Monday board from previous question
Food will be provided for in-person sessions. Please list all your dietary restrictions. If none, type NA.
*
Which session(s) will you attend? Select all that apply. (These are drop-in sessions, come to most or all.)
*
Thurs. Aug. 10th 6-8pm (virtual)
Thurs. Aug. 17th 6-8pm (in-person)
Thurs. Sept. 21st 6-8pm (virtual)
Thurs. Sept 28th 6-8pm (in-person)
Thurs. Oct. 19th 6-8pm (virtual)
Thurs. Oct. 26th 6-8pm (in-person)
Answers routed to Monday board from previous question
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Media Release Acknowledgement
I understand that Brown Mamas (BM) may take photos and/or videos of me during the course of my volunteer work. I hereby consent to BMs use of my image, voice, name, story, likeness, and any work product I may be create for BM throughout the term of this Agreement (collectively, my “Likeness”), in BM’s digital and print promotional materials, fundraising efforts, educational materials, social media posts, videos, and other communications. BM may use my Likeness without obtaining any further approval or paying me for its use. I grant BM all intellectual property rights in, and waive any legal claims relating to BM’s use of my Likeness, including copyright, rights of publicity or privacy, defamation, or those arising from any editing of the images, videos, and/or other materials.
Sign Below
I have read, fully understand and agree to the assumption of risk, waiver, release, hold harmless, indemnification, and use of Likeness terms set forth above. I understand that by signing this document I am giving up certain rights and accepting certain duties.
I Acknowledge & Accept
I Decline
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Need childcare?
After submitting this form, you will be directed to the "thank you" page where you can register for childcare. Request MUST be submitted at least 7-10 days prior to event/session.
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Got questions/comments?
Submit
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