Your Information Please provide your information below. If you are registering any additional attendees, you will add their information later.
Emergency Contact We are collecting Emergency Contact information for these events. Should a seizure or other medical situation arise for you during the group time, we need to have access to an emergency contact, and your physical location address. This information is not shared outside of EFMN staff unless they need to contact EMS services to respond to your home to provide medical care.
Additional Information These questions help EFMN ensure we are reaching everyone in our community and help us to receive grants to fund our programming. Thank you!
State Please select... AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY DC
Gender Please select... Male Female Non-binary Other Prefer not to answer Transgender Intersex
Race Please select... American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Mixed Race White Prefer Not to Answer
Ethnicity Please select... Hispanic, Latinx or Spanish Origin Not Hispanic, Latinx or Spanish Origin Prefer Not to Answer
