Afya Sanaa Membership applicationAncestral. Collaborative. Healing. Applicant Name * First Name Last Name Preferred Name Do you identify as Black, African, African American, ADOS? * Yes No Email * Mobile Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birthday MM DD YYYY Check all that apply I want to participate in Workshops and Classes I want to participate in Programs I want to book sessions for Healing Services I want to help or volunteer I want to facilitate a class or workshop My organization wants to partner w/ Afya Sanaa Personal Reference Name * First Name Last Name Personal Reference Phone * (###) ### #### Personal Reference Email What is your occupation? How active are you at work? None (seated all day) Moderate (light activity, walking) High (regular movement, lifting) Tell us a little about yourself What are your health and healing goals? Personal Facebook Page Link Personal Instagram Page Link Personal Twitter Page Link Today's Date MM DD YYYY Thank you!
