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 :
 
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: :
Have you experienced homosexual attractions in your life?  (Please be advised that the volunteer staff are not trained in Gay Affirmative Therapy.  If your attractions are symptomatic of emotional issues, then this weekend will be helpful to you.  Otherwise, if you are looking for G.A.T. we suggest you do not register for this event).  
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).

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