JIMENA Together & Buddy System Form
Please fill in your information and answer the questions below and we will follow up.
Thank you!
OK
1.
Name
2.
Email address
3.
Age Range
4.
Where do you live?
5.
What is your phone number?
6.
If you are filling out this form for someone else please provide their name, age, location, preferred language, contact info, and anything else you think we should know.
7.
I am interested in becoming a JIMENA buddy to (click all that apply):
someone my age
someone older than me
someone younger than me
8.
I am interested in joining a JIMENA Together Session
Yes
No
9.
Anything else you would like to tell us? Please share in the box below!
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