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* 1. Your name

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* 2. Your email address

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* 3. Please provide us with your mailing address and telephone number:

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* 4. What sparked your interest in this program?

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* 5. In a short sentence or two, please describe any past writing experiences, either positive or negative.

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* 6. We believe writing can be life-giving. How are you hoping that writing about your life might be a good thing for you?

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* 7. Which areas of writing appeal to you? Please check all that apply.

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* 8. Please indicate your age range.

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* 9. Is there anything else you would like to share about yourself?

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* 10. Would financial help with childcare/eldercare or transportation be helpful to you?

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* 11. Can you think of any barriers that would prevent you from taking part on a monthly basis?

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