480-668-8301
1745 S. Alma School Rd Suite 230
Mesa, AZ 85210
  Toll Free: 1-800-614-8142

AIM Weekend Registration

 

Participant Details
First Name :
Last Name :
Address 1 :
Address 2 :
City :
State/Province :
Zip/Postal Code :
Country :
Email Address :
Cell Phone Number :
Age :
Please list any food allergies or special needs :
 
Name of Mentor or Buddy
First Name :
Last Name :
 
Name of Emergency Contact
First Name :
Last Name :
Phone Number of Emergency Contact :
Describe Any Health or Medical Conditions:
If the participant questions his ability to safely engage in AIM weekend activities, he should first consult a physician.
:
Describe Any Hospitalizations for Mental Health Reasons: :
     
What needs, wounds, or deficits do you have regarding men? :
What needs, wounds, or deficits do you have around masculinity? :
What needs, wounds, or deficits do you have regarding women? :
Please describe any abuse you have experienced: :
Please explain any suicidal thoughts or attempts: :
Please explain any emotional issues or wounds you have about your body: :
Please describe any current addictions you are struggling to overcome: :
Please describe any goals you have for yourself while on this weekend: :
Can you pay a $200 donation toward the weekend? : Yes

I need financial assistance.  Please contact me about this.

(No one will be turned away.  Let us support you financially if you you'd like to come!  Support is provided by a generous grant given by the Marley Kemper Foundation.  Your copay could be as low as $10).

   Yes
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