Sign up for ProACTIVE

Thank you for your interest in this program. ProACTIVE is a group for men that want to learn healthy relationship skills. If you are interested in participating in ProACTIVE, please complete this short survey and we will reach out about your participation. Groups will be scheduled based on the availability of participants and facilitators with new groups beginning as interested participants sign up. Please email ProACTIVEIowa@gmail.com or call (515) 650-3692 with any questions.

First Name

Last Name

Please provide an email address below. (Please enter "NA" if you don't have one)

Please provide a phone number below.

What type of meeting would you like to attend?

An African-American or Black group

A Spanish-speaking or Hispanic group

A White group

Are you 18 years old or older?

Yes

How did you find out about this program?

This program does not operate within or collaborate with the criminal-legal system or the Iowa Department of Health and Human Services (DHS). In other words, written or verbal communication confirming participation in this program will not be provided to criminal-legal entities (e.g., probation or parole officers) or DHS. This policy is designed to preserve the voluntary nature of this program, which we believe will enhance the experience. Please indicate whether you agree to these terms below. (Note: You must agree to participate.)

Yes

If you would like us to provide childcare, please provide the number of children and their ages below.

Please provide your full address below. This information is required for providing the $25 compensation per session and will not be used for other purposes. If you are not interested in the compensation, you may skip this question and enter "NA" below.

Sign up for ProACTIVE

First Name

Last Name

How would you like us to contact you? Please select all that apply.

Please provide an email address below. (Please enter "NA" if you don't have one)

Please provide a phone number below.

What type of meeting would you like to attend?

What is your race?

Are you 18 years old or older?

How did you find out about this program?

If you would like us to provide childcare, please provide the number of children and their ages below.

Please provide your full address below. This information is required for providing the $25 compensation per session and will not be used for other purposes. If you are not interested in the compensation, you may skip this question and enter "NA" below.

Sign up for ProACTIVE

1. First Name *

2. Last Name *

3. How would you like us to contact you? Please select all that apply. *

4. Please provide an email address below. (Please enter "NA" if you don't have one) *

5. Please provide a phone number below. *

6. What type of meeting would you like to attend? *

7. What is your race? *

8. Are you 18 years old or older? *

9. How did you find out about this program? *

11. If you would like us to provide childcare, please provide the number of children and their ages below.

12. Please provide your full address below. This information is required for providing the $25 compensation per session and will not be used for other purposes. If you are not interested in the compensation, you may skip this question and enter "NA" below. *

First Name

Last Name

How would you like us to contact you? Please select all that apply.

Please provide an email address below. (Please enter "NA" if you don't have one)

Please provide a phone number below.

What type of meeting would you like to attend?

What is your race?

Are you 18 years old or older?

How did you find out about this program?

If you would like us to provide childcare, please provide the number of children and their ages below.

Please provide your full address below. This information is required for providing the $25 compensation per session and will not be used for other purposes. If you are not interested in the compensation, you may skip this question and enter "NA" below.