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EEC Healing Weekend Registration June 12-14, 2026
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1.
First and Last Name
(Required.)
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2.
Preferred Email:
(Required.)
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3.
Mobile #:
(Required.)
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4.
Home Zip Code:
(Required.)
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5.
Work Zip Code
(Required.)
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6.
Are you a person of African descent?
(Required.)
Yes
No
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7.
What is your ethnicity/culture?
(Required.)
African American
African
Afro-Latino
Afro-Caribbean
Black American
Other (please specify)
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8.
What is your age range?
(Required.)
18 - 29
30-39
40-49
50-59
60-69
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9.
How would you describe your gender? (check all that apply)
(Required.)
Female
Male
Non-binary
Prefer to self-describe as: ____________ (gender-fluid, agender, genderqueer, please specify)
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10.
I identify as a person of Trans experience
(Required.)
Yes
No
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11.
Preferred Pronouns:
(Required.)
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12.
Have you attended Emotional Emancipation Circles before?
(Required.)
Yes
No
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13.
Who referred you to the EEC?
(Required.)
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14.
Do you have any dietary needs?
(Required.)
No, I do not have any dietary needs.
Vegetarian
Vegan
Kosher
Gluten-free
Other Allergy (please specify):
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15.
Do you have any special needs we should be aware of?
(Required.)
Yes
No
If Yes, Please Specify:
16.
What do you hope to learn about yourself through participating in the Emotional Emancipation Circle?
Send me a copy of my responses via email
