Wey of Life PRC Kiosk Member Form

Thank you for your interest in becoming a member!!

While membership at Wey of Life PRC is geared towards individuals in recovery from substance use disorder and their families, there are specific groups that are open to all and plenty of ways to give back and get involved. See a staff member to learn more.

Questions marked with a red asterisk are required. Data is reported anonymously and helps us to understand the community we serve and report on required demograhpic information for our grant.

Name*

First NameLast Name

Gender*

Date of Birth*

mm/dd/yyyy

I identify as:*

Recovery Date

mm/dd/yyyy

Phone Number*

Please enter a valid phone number.

Email

example@example.com

For your address, if you are experiencing homelessness - please input homeless in Street Address bar and fill out the City, State, and Zip Code you most associate with.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Highest Education Level Completed*

Are you Spanish/Hispanic/Latino?*

What is your primary ethnicity?*

Examples: American, African, Chinese, Middle Easter, Haitian, Cuban, Puerto Rican, etc.

What do you consider your race?*

Examples: White/Caucasian, Black/African American, Asian, etc.

T Shirt Size

Do you provide your consent to being contacted by our organization regarding upcoming events, new, or other activities?

I consent

Do you provide consent to have your personal health information stored by Wey of Life Peer Recovery Center and demographic information utilized for grant reporting?*

I consent

Wey of Life Member Form