Register for Black Up Wellness Circles

Your Contact Details

Full name

Preferred name (optional)

Phone or email

Please contact me by

PhoneTextEmail

Toronto neighbourhood or first three characters of postal code

Participation

I would like to attend

In personOnlineEither

What would make participation accessible for you?

For example, large print, interpretation, step free access, or a different way to communicate. You do not need to provide a diagnosis.

I would like staff to contact me privately about an access need

How did you hear about this program?

Friend or familyAFIWI websiteCommunity partnerOther

About Your Interest

Eligibility

I am a Black woman interested in this programI would like to discuss eligibility privately

What would you like to gain from the circles

Would you prefer a staff member to speak with you privately before your first session?

YesNo

Black Up is a community program. Facilitators do not provide therapy, clinical care or crisis support.

Privacy and Contact

AFIWI will use the information on this form to respond to your request, plan participation and contact you about this program. Staff will share it only with people who need it to arrange the program, subject to AFIWI's privacy practices. Please ask staff how to access or correct your information.

I understand AFIWI may contact me about this registration

Optional permissions. These do not affect registration.

I agree to receive news about other AFIWI activities

I agree to be contacted after the program for feedback

Photo or video permission, if needed, must be requested on a separate form.

Typed name

Type your full name to sign this registration.