Vital Cycles Group Registration Form (Text Version Instructions: Please copy and past this into an email, and fill out as completely as possible. Fields that marked with *** are required. Please send the completed form to webadmin@vitalcycles.org This is the text only version of the form. If you have Microsoft Word, please download the regular version. At the present time, all of our meetings are listed only on the internet. By submitting this form, you agree to list your meeting on our website at www.vitalcycles.org. Please send any question or comments about this form to webadmin@vitalcycles.org ------------------------------------------------------------------------------------------------------------------------------- Meeting Information: A valid email address, first name and phone number must be provided in order for group’s to be listed. The information is used to send occasional Vital Cycles news, and to confirm meeting listing accuracy. *** Meeting Type: (Ex, Online, Phone, Regular Discussion) *** Frequency of Meeting (Ex, Every Week, Monthly, etc) *** Meeting Name: *** Meeting Day: *** Meeting Time: Name of Meeting Location (ex: Town Senior Center) Address: *** Town/City: *** State: *** Country: United States Meeting Location within Building: Special Notes and/or Directions: ------------------------------------------------------------------------------------------------------------------------------- Primary Group Contact Information: A valid email address, first name and phone number must be provided in order for group’s to be listed. The information is used to send occasional Vital Cycles News, and to confirm meeting listing accuracy. ***First Name: Last Name: ***Primary Phone Number: Alternate Phone Number: ***Email Address: Mailing Address: Town/City: State: Country: United States Can we send you Vital Cycles News? Yes Can we list your First Name and Primary Telephone? Yes Can we list your email address? Yes Please note, we recommend using an email address that does not have your name or place of work in it. ------------------------------------------------------------------------------------------------------------------------------- Secondary Group Contact Information This information is only used if the primary contact is not available. (Except for sending Vital Cycles news.) First Name: Last Name: Primary Phone Number: Alternate Phone Number: Email Address: ***Can we send you Vital Cycles News? Yes ***Can we list your First Name and Primary Telephone? Yes ***Can we list your email address? YesPlease note, we recommend using an email address that does not have your name or place of work in it. ------------------------------------------------------------------------------------------------------------------------------- Meeting Characteristics Please define the characteristics of your group. The focus is used to identify one or two areas that your group focuses on during most meetings. The Guidelines and Invitations are used to clearly invite groups of people, and/or restrict others. Primary Group Focus Please put an X in front of the one or two areas your group will focus on. __ All Trauma __ All Childhood Trauma __ All Emotional Trauma __ Childhood Emotional Abuse __ Childhood Neglect __ Childhood Verbal Abuse __ Adult Emotional Trauma __ All Military Trauma __ War/Battle Trauma __ Physical Trauma __ Childhood Physical Abuse __ Adult Physical Trauma __ Sexual Trauma __ Childhood Sexual Abuse __ MPD / DiD0Ritual/Cult Abuse __ Adult Sexual Trauma __ Bereavement Meeting Guidelines and Invitations Please put an X in front all that apply. __ Everyone Welcome __ Pro-survivors Welcome __ All Members Welcome __ Newcomers Welcome __ Newcomers- Call Before Attending __ Men Only0Woman Only __ Gay/Lesbian Only __ MPD/DID Only __ No Current Perpetrators of Sexual Abuse __ No Current Perpetrators of Physical Abuse __ Sex Abuse Survivors Only __ Childhood Sexual Abuse Surviors Only __ RA/ Cult Abuse Survivors Only __ Military Trauma Survivors Only __ Additional Group Guidelines: Call Before Attending for information