Summer Series
July 6th – August 17th 2022
6:30-8:30 pm Wednesdays

Facilitated in English through Zoom

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* ADULT Participant (18+)

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* Sex:

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* Date of Birth:

Date

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* Our program will be providing you informational handouts during the class series. How would you prefer to receive them?

Please check your preference:

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* Address:

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* County:

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* Email Address:

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* Phone Number:

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* Homeless?

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* All information is confidential

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* Are you Spanish/Hispanic/Latino?

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* Are you an immigrant or refugee or new arrival to the U.S.?

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* Have you ever served on active duty in the U.S. military (inc. Natl. Guard/Reserves)?

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* Are you a spouse or partner of a US military person?

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* Language(s) spoken at home:

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* Are you non-English speaking or of limited English ability?

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* Do you have a special need/disability?

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* Are you a parent, family member or caregiver of a child with a special need/disability?

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* Children:

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* Please check the age of each child in household:

  0-11 months 1 3 4 5 6 7 8 9 10 11 12 13 14 15+
Child 1:
Child 2: 
Child 3: 
Child 4: 
Child 5:
Child 6:
Child 7:
Child 8:

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