Connections application

Connections Class Application
Connections: Healthy Relationships with Family, Friends, and Partners

Connections is an in-person course that consists of 8 classes sponsored by Independence Northwest. This class is about relationships and sexual health and will help you reach out and build stronger connections with the people you care about.The Connections class will give you tools to be safe and happy in your relationships.Please note that attendance at every class in the series is important because each class builds on the one before.If you have any questions, don't hesitate to reach out to one of the instructors(Corinne or Alice) by emailing us at connectionspeople@gmail.com.
What is your name?
Please share your contact information with us

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Would you like to add an additional contact for us to communicate with (such as a family member, support person, provider, or friend) please share their name, phone, and email address below
Name of additional contact
Email for additional contact
Phone number for additional contact
Which brokerage do you receive services from?
What is your Personal Agent's name?
What is your Personal Agent's email address?
What is your age?
What are your preferred personal pronouns?
Comments on pronouns
In your own words, why do you want to take this class?
What types of relationships do you want to learn more about?
Please rate your interest on the class topics outlined below
Topic #1: "Communication-how we can communicate better with friends, family, and partners"
Comments on Topic #1
Topic #2: "What is public and what is private?"
Comments on Topic #2
Topic #3: "What is a healthy relationship? What is an unhealthy relationship?"
Comments on Topic #3
Topic #4: "Gender identity and sexual orientation"
Comments on Topic #4
Topic #5: "Using social media: internet and phone safety"
Comments on Topic #5
Topic #6: "Moving from friend to partner (romantic feelings, sexual feelings, dating, intimacy)"
Comments on Topic #6
Topic #7: "Consent. What is yes? What is no? Saying NO."
Comments on Topic #7
Topic #8: "Exploitation and abuse in relationships"
Comments on Topic #8
Topic #9: "Understanding our bodies (anatomy, sex, and sexual health)"
Comments on Topic #9
Topic #10: "Reproduction (birth control, pregnancy, parenthood)"
Comments on Topic #10
Do you have any other topics you'd like us to address?
Comments
Do you need a support person to be in the classroom to support you with medical needs, or with needs related to use of an alternative/augmentative system for communicating?

Yes
If yes, please describe the nature of any required supports:
Other support staff are welcome to be present and available in our lobby to check in with students during the break and before/after class.
Please let us know of anything we should be aware of to ensure your safety and success in class. Are there accommodations that help you participate and learn best in a classroom setting?
If yes, please describe:
How do you feel about being in a classroom setting and learning with other people?
Do you have any medical concerns or protocols the instructor should be aware of to ensure your safety?
If yes, please describe:
Do you have a behavior support plan in place?
How will you travel to the Independence Northwest office?

Other
Who completed this application?
The name of the person that helped me is:
Please share contact information for who you would like us to contact in the event of an emergency.
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have anything else you would like to share with us?
Note: You can always change answers from earlier in the application before submitting. Just scroll up and make changes!
By checking the box below, I understand and authorize Connections class instructors to communicate with my Personal Agent, family, support person, providers, or anyone listed in question #3 regarding this application. I understand that this release is required in order to provide the best possible class experience.
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Connections Class Application

Connections: Healthy Relationships with Family, Friends, and Partners

Please rate your interest on the class topics outlined below

Please share contact information for who you would like us to contact in the event of an emergency.