홉앤웰니스

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(Check all that apply. If you are flexible, click the “I’m flexible’ option)

I’m flexible Mornings (10am-12pm) Afternoon (12-5pm) Evenings (5-7pm) Mondays Tuesdays Wednesdays Thursdays Fridays

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I agree that staff at Hope & Wellness Services may receive this information electronically and may communicate with me electronically at the email address provided. I understand that this form is not protected communication; as email transmissions are capable of being intercepted, any confidential information that is sent or received cannot have its privacy absolutely guaranteed. By requesting a response to my inquiry, I acknowledge that I am aware of the risks to my privacy and consent to the above terms, limits, and risks.

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