Adult Expressive Arts Group Participant Registration Form
Hello and thank you for your interest in the Adult Expressive Arts Group at Radical Healing! This group will begin on 4/24/2024 and meet for 5 consecutive weeks on Wednesdays from 5pm-7pm. This group will meet in person at Radical Healing's Movement Space, located at 2007 Chapel Hill Road in Durham, NC.

We are excited to do this needed work in our community. If you're interested in being a group participant, 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. 

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 *
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DD
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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
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 meet in person at Radical Healing's Movement Space, located at 2007 Chapel Hill Road in Durham, NC. Due to the content and format of the group, there will be no option to join virtually. Do you expect that you will be able to attend sessions in person at this address? *
What concerns do you have about potentially participating in this group?
For this group, we are suggesting a donation of $30 per session to participate, but are allowing participants to pay whatever they can given their unique financial circumstances. 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. *
Would you like to utilize our "tuition" model for payment, or pay for each session individually? (Please put "I don't know" if you would like us to ask you again when it is closer to the group's start date.)
Do you think you can commit to meeting once a week for 2 hours, for 5 total weeks?  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 environment more conducive to your involvement? Please include allergies if applicable.
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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