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Artful Wellness Referral
Please fill out this form to refer someone in financial need for a tuition free workshop at the ARTfactory.
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* Indicates required question
Email
*
Your email
Referral Partner's Last Name
*
Your answer
Referral Partner's First Name
*
Your answer
Participant's Last Name
*
Your answer
Participant's First Name
*
Your answer
Guardian's Name (If participant is under 18)
*
Your answer
Participant's Age
*
Your answer
If a minor, what school does the participant go to?
*
Your answer
Participant's Home Zip Code
*
Your answer
Participant's or Guardian's (if participant is a minor) Email
*
Your answer
Participant's or Guardian's (if participant is a minor) Mobile Phone
*
Your answer
Workshop Title Participant wishes to attend. (You must fill out a separate form for each class.)
*
Meditative Drumming Workshop 5/11 1-2pm
Option 2
Please describe any special accommodations we need to take into account for this participant. (If none, please write N/A.)
*
Your answer
What organization did you refer the participant from?
*
Your answer
Why do you believe this participant will benefit from this referral?
*
Your answer
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