ENM/Poly Educational Group Registration Form
Hello and thank you for your interest in the ENM/Poly Educational Group at Radical Healing! (Meaning ethical non-monogamy and polyamory, respectively.)

We are excited to do this needed work in our community. If you're interested in being contacted when our groups open up registration, please complete the following form. Please note that completing this form does not automatically guarantee your participation in the group - this form is designed to help you let us know your interest in the group, give us more information about you, and save you some time filling out paperwork later in the event that you do become an official group participant.

IMPORTANT: Each individual person who wishes to participate needs to complete their own registration form.

Since this form is transmitted electronically, confidentiality cannot be guaranteed. If there is any question you prefer not to answer, please let us know by completing the last form response and we can schedule a time to meet with you over the phone or in person.
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Full Name (first and last) *
Legal Name (if different)
Pronouns *
Required
Race/Ethnicity (This question helps us ensure we create safe-r group environments by ensuring we have a diverse community represented in our group.) *
Required
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Address *
Email *
Emergency Contact (Name, Relationship, Phone #)
 *
Do we have your consent to...(the more options you select, the easier it is for us to get in touch with you!) *
Required
We are asking that for the duration of this group (6 weeks), all participants refrain from forming new romantic or sexual relationships with any other group participants. This will ensure that this group remains a space for prioritizing community-building and learning. By initialing here, you are indicating that you have read this, understand it, and agree to it.
 *
This group is intended for folx who are either currently practicing a form of ENM/polyamory, or who identify as curious to explore/learn more about ENM and polyamory. Please select which applies to you:
 *
How did you hear about Radical Healing and/or this group?
What are you hoping to learn or gain from experiencing this group?
This group will only meet virtually. Do you have the needed components (device, WiFi) to participate in a virtual group?
Clear selection
What concerns do you have about potentially participating in this group?
For this group, we are suggesting a donation of $25-$40 per session to participate, but we will not turn away any potential participant for lack of funds. Please indicate how much you can afford to pay per group session. *
If paying to participate, there are two options for payment: you can pay for each session individually, or you can pay for all sessions in advance/on the first day your group meets (called our "tuition" option). If you utilize the "tuition" option, we are reserving the space for you throughout the duration of our entire group and if you miss a group session for any reason, including illness, there will be no refunds issued. This is to help ensure our facilitators are compensated fairly and our facilities can continue to be maintained and used.
By putting your initials here, you are acknowledging that regardless of what payment method you select, you have read and understood this information. *
Do you think you can commit to meeting on Tuesdays from 6:30pm-8pm for 6 weeks beginning on March 5th?  If not, what are some hurdles that may get in the way? *
Do you have any accessibility needs or other considerations that can make the virtual environment more conducive to your involvement? 
If you have general questions for the facilitators or other information you would like for us to have, please use the space provided below.
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