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AC Groups - Organization Application Form

Questions marked with a * are required

1.First Name

2.Last Name

3.Phone Number

4.Email Address

5.Organization Name

6.Location (city, state)

7.Occupation

8.Are you in a leadership position?

Yes

9.Gender

Female

Male

Other

10.Relationship Status

Single

In a committed relationship

Married

Other

11.If you are a parent, please indicate the age range(s) of your child(ren)

Baby: 0-12 months

Toddler: 1-3 years

Preschool: 3-5 years

Gradeschool: 5-12 years

Middle School: 12-15

High School: 15-18

Young adult: 18-21 years

Adult

Other

I do not have any children

12.Why do you think Authentic Connections Groups might benefit you and/or your organization?

13.Please check all times you are available or that may work (assuming a few weeks' notice) to attend weekly, one-hour groups:

14.Is there anything else that you would like us to know?