Training with Nikki                                                  Virtual Community Wellness Workshops Registration Form 
Welcome to the Training With Nikki Community! This (one time) registration form will give you complete access to all of our 2023 Virtual Community Wellness Workshops starting May 2023!
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First/Last name  *
Email Address *
Social Media Handle (Instagram + Facebook) 
Phone Number *
What state /county do you reside? 
*This will help determine if we are reaching our target population*
 *
5 Question Survey 
To ensure our program helps meet your needs and is reaching our target population - please answer the 6 question survey below. Thank you 

Please indicate how you identify yourself?

*

What is your age?

*

Do you consider yourself to be a caregiver (mother and/or caring for disable family)?

*

How would you rate your overall physical and mental well being?

 *

How would you receive access to physical and mental community wellness services, if this (virtual) resource was not available?

*
What is one of your wellness goals that I can help you achieve with these workshops?   *
How did you hear about Training With Nikki - Community Wellness Workshops?  *
I have read and agree to the liability waiver.  *
Captionless Image
Required
I understand that photos and videos may be taken (and used), for but not limited to publication on any Training With Nikki platform. I understand that no payment will be made for participation in this release.  *
Required
We appreciate your donation (at any amount) which helps support our program and the communities we serve.

Please submit your optional donation here: 

*Class value per entry = $10 - $30 

Thank you for your support & see you in class! 
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