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Empowered Circle with EbonyB Group Application Form
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1
Name
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First Name
Last Name
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2
Email
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example@example.com
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3
Are you a Black woman?
*
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This group is for Black women only. Being biracial with any Black heritage is absolutely considered being a Black woman, and you are welcome here. This space is intended to center and uplift the unique experiences of Black women, and we want everyone who identifies within that to feel seen, heard, and supported.
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4
Why are you interested in joining Empowered Circle with EbonyB?
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What does empowerment mean to you as a Black woman?
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6
What topics or issues are you most interested in discussing or learning about within the group?
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Are you currently pregnant, do you have children, or have you experienced pregnancy loss?
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Please share as much as you feel comfortable sharing.
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8
Have you ever had a situation where you didn’t feel heard or respected by your medical team?
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Please share as much as you feel comfortable sharing.
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9
How do you plan to contribute to the community (e.g., sharing experiences, providing support, participating in discussions)?
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