GROWing Fighters Registration Name *Nickname *DOB *Gender/Gender Identity *Race *American Indian/Alaska NativeAsianBlack/African-AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteOther/Multi-RacialStreet Address *Apartment, suite, etcCityState/ProvinceZIPPhoneEmail AddressWhat is the safest method to contact you? *Is safe to leave voicemails or send texts/emails? *What topics are you interested in learning more about and/or discussing? Please check all that apply. *Domestic Violence/Intimate Partner ViolenceSexual AbuseTrauma/PTSDRelationshipsMental HealthCoping SkillsSelf-HarmSelf-CarePhysical Health/FitnessCommunity Resources/ReferralsFamily ConflictParentingSpiritualityOtherIf you selected "Other", please explainThe cost to attend the group is $10.00 per session. Would you like to be considered for a membership sponsorship? *Yes (Approval based on review of survivor’s financial circumstance and resource availability)NoGROWing Fighters meets every 3rd Saturday of the month in six-month increments: January-June (first session) and July-December (second session). Can you commit to attending at least 5 of 6 of the scheduled meetings in your designated session? *YesNoUnsureIn a few sentences or less, please share what you hope to gain from this support group *Confidentiality Agreement *I agree with the following statements: I understand that, as a participant in G.R.O.W. Foundation’s “GROWing Fighters Domestic Violence Survivor Support Group”, I may encounter confidential information. As part of the condition of my participation, I hereby agree to keep in strict confidence any private or sensitive information received or disclosed by any survivor, attendee, participator, facilitator, or representative of G.R.O.W. Foundation. This information includes but does not limit to identities of the survivor and/or their family, identities of the perpetrator and/or their family, details of abuse/trauma, pending or adjudicated legal matters, and medical history. I will do this in accordance with G.R.O.W. Foundation’s privacy policy and applicable laws, including those that require mandatory reporting. I acknowledge that it is my responsibility to respect the privacy and confidentiality of this information, as well as my fellow group members, and understand that breach of my responsibility may result in my removal from the “GROWing Fighters Domestic Violence Survivor Support Group”. I understand the obligations and restrictions set forth under this agreement are effective immediately upon the execution of this agreement and shall indefinitely survive the final date of my participation as a member of “GROWing Fighters Domestic Violence Survivor Support Group”.Signature *Today's Date * Submit