AIM Registration

	(480) 668-8301
	6402 E. Superstition Springs Blvd., Mesa AZ, 85206
	Toll Free: 877-271-9389

AIM Weekend Registration

Participant Details
First Name	:
Last Name	:
Address 1	:
Address 2	:
City	:
State/Province	:
Zip/Postal Code	:
Country	:
Email Address	:
Cell Phone Number	:
Age	:

Name of Mentor or Buddy
First Name	:
Last Name	:

Name of Emergency Contact
First Name	:
Last Name	:
Phone Number of Emergency Contact	:
Describe Any Health or Medical Conditions: If the participant questions his ability to safely engage in AIM weekend activities, he should first consult a physician.	:
Describe Any Hospitalizations for Mental Health Reasons:	:
Have you experienced unwanted same-sex attractions?	:
What needs, wounds, or deficits do you have regarding men?	:
What needs, wounds, or deficits do you have around masculinity?	:
What needs, wounds, or deficits do you have regarding women?	:
Please describe any abuse you have experienced:	:
Please explain any suicidal thoughts or attempts:	:
Please explain any emotional issues or wounds you have about your body:	:
Please describe any current addictions you are struggling to overcome:	:
Please describe any goals you have for yourself while on this weekend:	:
I agree to pay $225 as a donation for this weekend.	:	Yes
Yes, I want to receive Family Strategies' newsletter	: