Wey of Life PRC Kiosk Member Form

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

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