Full Name *
Full address *
Email *
Phone *
Gender *	Male Female Non-binary Undeclared
Age *
	DISCLAIMER: By participating in the 5th Annual Walk hosted by Keep Your Hands Off Me, Inc., I accept all risks involved, including injury or accident, and release the organizers, sponsors, and affiliates from any liability. I confirm I am medically fit to join and grant permission for my image to be used in event media. *

Service Registration

Full Name *
Phone *
Email Address *
Date of Birth *
Preferred Method of Contact: *	Phone Text Email
Select the Service(s) You're Registering For: *	6-Week Bootcamp Case Management Parenting Course Holistic Healing Peer Support Group Teen Talk
Reason for Joining/ Goals *
Do you have any medical conditions or special needs we should be aware of? *
If yes, please explain:
	I voluntarily agree to participate in the selected services and understand that these programs are designed for personal development, education, and support purposes only. *
	I understand that all personal information I provide will be kept confidential and used solely for service coordination. My information will not be shared without my written consent unless required by law. *
Signuture *

KEEP YOUR HANDS OFF ME, Inc.

1506 Market Street Suite A/B
Wilmington, NC 28401

info@keepyourhandsoffme.org

Main: 910-833-5119

910-233-6926

DONATE NOW!

Financial information about this organization and a copy of its license are available from the State Solicitation Licensing Branch at 919-814-5400. The license is not an endorsement by the State.