name_eventthankscancellationENROLLEE INFORMATION: Name: Date of Birth:Day:---12345678910111213141516171819202122232425262728293031Month:---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear:---19371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010 Address: City: State: Zip Code: Home Phone: Cell: Email address: Do you speak:EnglishSpanishBilingual What's your ethnic background? (not required but helpful to AHA!)SURVEY What brings you to want to participate in an AHA! Connect group? Is there anything you would like your facilitators to know before you participate (for example, if you have a mental health diagnosis, a history of trauma, or medical issues)?How did you find out about AHA! Connect Groups? N/APersonal referralTherapist or other professional referralNews mediaSocial mediaOther Name: Phone: Position/Title: Email:EMERGENCY CONTACT INFORMATION: Name: Relationship: Home Phone: Work Phone: Cell Phone: Email:We offer our Connect programs by donation. Please donate what you can; any amount is accepted. Thank you for supporting AHA! Click here to donate.Note: If your family is unable to donate due to hardship please contact Roxy at roxana@ahasb.org