Adult Connect Form - AHA! Santa Barbara

ENROLLEE INFORMATION:

Name:

Date of Birth:

Day:

Month:

Year:

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?

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