FOWI Healing Hub
A safe space for justice impacted to gain additional resources for a successful re-entry
What is your Full Name
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First Name
Middle Name
Last Name
What is your date of birth?
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list your Primary Phone Number
*
-
Area Code
Phone Number
Email Address
*
What gender do you identify as?
*
Female
Male
Prefer not to say
Other
Have you or a Family Member been impacted by police brutality? Please select all that apply
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Myself
Spouse
Parent
Sibling
None
Other
What topics do you advocate for? Please select all that apply
*
Women's Rights
Education
Justice Reform
Housing/Homelessness
Parole & Probation
Employment
Entrepreneurship
Healthcare
Gender Equality
Racial Equality
Addiction
Spiritual Empowerment
Police Reform
Other
Do you have experience speaking publicly?
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Yes
No
Education Background
High School Diploma/GED
Associates
Bachelors
Masters
Other
Would you be able to commit to the 8 week program requirements?
*
What do you wish to gain from this experience?
How did you hear about this program?
*
The LOHM Website
An LOHM employee
Social Media
Other
Signature
Submit
For questions please contact Patricia Lewis - plewis@thelohm.org
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