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Mashkiwizii Manido Foundation Intake Form
Confidentiality statement. Consent declaration.
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* Indicates required question
Email
*
Your email
Full Legal Name
Your answer
Email Address
Your answer
Spirit Name or Chosen/Preferred Name
Your answer
In order for us to better serve your unique needs, please check one of the following
First Nation Status
First Nation Non Status
Inuit
Metis
Kin
Non Indigenous Ally
What is your age range
Choose
under 16 years old
16 to 30 years old
31 to 45 years old
46 to 60 years old
over 60 years old
Contact Information and Mailing Address?
Your answer
Emergency Contact Information
Your answer
How did you hear about us?
Your answer
What program or activity are you interested in participating in? (Please check all that apply.)
Men's Sharing Circle
Women's Sharing Circle
2-Spirit and Indigiqueer Sharing Circle
Community Sharing Circle (Friday Morning Circle)
Indigenous Community Crafting
Wisdom to Wellness Wednesdays
Drumming Circle
Grief Support Circle and Death Cafe
KAIROS Blanket Exercise
Seasonal Gatherings
Land-Based Activities/Ceremonies
Counselling
Culture Camps
Culture Awareness Training
Other:
Are you interested in receiving our newsletter?
Yes
No
Clear selection
Signature
Your answer
Date
MM
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DD
/
YYYY
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