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MHA Support Group Registration Form & Waiver Form
Thank you for your interest in our support group(s). Please fill this quick registration form (your answers will be anonymous and confidential).
Registration Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Group:
Anxiety Support Group
TIDES Support Group
TIDES Online Support Group
Schizophrenia/ Schizo-Affective Support Group
Do Not Know
General Information
Name
*
First Name
Middle Name
Last Name
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Birth Date
*
-
Month
-
Day
Year
Date
Ethnicity
Please Select
Prefer Not To Answer
African American
Hispanic/ Latino
Asian
Caucasian
Native American/ Alaskan
Hawaiian/ Pacific Islander
Middle Eastern
Other
Gender
Please Select
Prefer Not To Answer
Female
Male
Self-Identified
Gender Non-Confirming
Other
Income
Please Select
At or below $12,490
Between $12,491 and $18,735
Between $18,736 and $24,980
Between $24,981 and $31,225
Above $31,226
Do Not Wish To Disclose
Residence Information
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
In the event of an emergency, I gave MHA permission to contact: (include their phone number)
Primary Emergency | Contact Name
First Name
Last Name
Primary Emergency | Phone Number
Please enter a valid phone number.
What is your relationship with this person?
Is there anything else you would like us to know?
Does the Mental Health Association in Forsyth County have your permission to send information about the agency including newsletters, upcoming special events, speaker meetings, trainings, closings/delayed openings in the event of bad weather, etc.? (NOTE: E-mail notices are sent via Mail Chimp. No one else can see your email address.)
*
Yes
No
By checking the box labeled "yes, I agree" below, I hereby release the Mental Health Association in Forsyth County (MHA), its officers, directors and employees, contract personnel, sponsors, personnel or any parties connected with MHA support groups, from any and all liability which may arise out of or relate to my participation in MHA support groups and I hereby waive all claims against such person(s) in connection therewith. Further, I know that I need to abide by the support group guidelines and I understand that failure to comply may result in my being asked to leave the group.
*
Yes, I agree
Signature
*
Clear
Submit
Mailed Thank You Note:
Yes
N/A- Does not wish to be sent mail
Note Date:
-
Month
-
Day
Year
Date
Should be Empty: