JIMENA Together & Buddy System Form

Please fill in your information and answer the questions below and we will follow up.

Thank you!

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* 1. Name

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* 2. Email address

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* 3. Age Range

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* 4. Where do you live?

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* 5. What is your phone number?

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* 6. If you are filling out this form for someone else please provide their name, age, location, preferred language, contact info, and anything else you think we should know.

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* 7. I am interested in becoming a JIMENA buddy to (click all that apply):

someone my age

someone older than me

someone younger than me

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* 8. I am interested in joining a JIMENA Together Session

Yes

No

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* 9. Anything else you would like to tell us? Please share in the box below!