AHAM Education (Academy of the Heart and Mind) Mind Body and Mindfulness Interest Form

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Thank you for your interest. Kindly fill out the form below. Your responses are held in highest confidentiality, are not distributed to other parties, and allow us to determine how to best serve the needs of those interested in our programs. Please contact knellee@ahameducation.org or (954) 873-4508 for questions or comments, or go to http://www.ahameducation.org to learn more about us.

First Name *

Last Name *

Please indicate the personal pronoun you would like to be called (she, he, they, zie, etc)

Best contact number *

Age *

Zip code where you reside *

Zip code where you work / attend school *

Email address *

How have you or your family been adversely affected by COVID? *

I am/head of household is unemployed or furloughed as a result of COVID

I am/head of household is an essential worker (health, public transportation, food service, community worker)

I and/or members of my family tested positive and/or suffered loss of a family member from COVID-19

My financial situation and health has not changed drastically, I am able to support my family and am in good health

Required

Please describe your racial/ethnic identity (check all that apply) *

Asian (East, South East, or Diaspora)

Black, African American or Afro-Caribbean diaspora

Hispanic / Latinx

Native American or Indigenous Population

Pacific Islander

White / Caucasian

Prefer not to say

Other:

Required

Please describe your gender identity (check all that apply): *

Female

Male

Non binary

Transgender

Prefer not to say

Other:

Required

Profession / Occupation *

Prior Experience with Mindfulness and Mind Body Tools (none necessary) *

Why do you want to take this program? What do you hope to gain? *

If you are applying for a scholarship, please explain why? If not, just write in N/A. *

How did you find out about this program *

Facebook / Other Social Media Marketing outlet

AHAM Education Website

Broward County Public Schools

Children Services Council

Mindful Cities / Mindful Ambassador

Community event

Friend / colleague / relative

Other:

Required

Thank you for your interest, we will be contacting you soon.

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