Art 4 Healing Participation Form
Participant Details:
Full Name
*
First Name
Last Name
Birth Year
*
Gender/Preferred Pronouns
Address (Zip Code is only required)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Please Select
Clark
King
Pierce
Snohomish
Spokane
Thurston
Yakima
Other
Phone Number
*
E-mail
*
example@example.com
Race
*
Please Select
African American/Black
Latine/Latino/A/X
Asian
Native Hawaiian/Pacific Islander
White
Two or more
How did you hear about the program?
*
Were you referred by a community partner?
Please Select
Yes
No
If yes, please specify.
Do you know someone who has been affected by the war on drugs and loss of loved ones due to gun violence and would like to add their name to the mural?
Please Select
Yes
No
Choose a session to join
Art Therapy Expression Sessions to provide you a voice through canvas to express the impacts of the "War on Drugs" to you and/or your family.
Which art sessions would you like to attend? If you attend all four sessions, there is a special gift for you at the end.
April 19 (3:30pm - 4:30pm)
April 26 (3:30pm - 4:30pm)
May 3 (3:30pm - 4:30pm)
May 17 (3:30pm - 4:30pm)
We are working with Eric Salisbury to develop a community mural (Mid April - Mid June 2025). The unveiling will take place at the end of June 2025. Are you interested in participating in the creative process of the mural?
Please Select
Yes
No
Submit
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