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Sign Up Form

  • Instructions

    1. Part A of this form registers you for the course. The rest of the application surveys your needs and evaluates your level of skill. 

    2. The information on this form is confidential and protected under HIPAA. This information will be only used for statistical purposes and to determine which services to provide. The information you submit online is also encrypted. 

    3. Please fill out each section as honestly as possible. We use this information to make our courses better. 

    4. Many questions are optional and you can choose not to respond. 

    5. Use full sentences in the last section; as we are assessing your writing skills.

  • PART A. REGISTRATION (required)

    • I am interested in registering for the course from Victim to Survivor to Offender. 

    • I am able to access the course online. 


  • PART B. SURVEY

    This helps us modify the course to better meet your needs and find the right tutor for you (all questions are optional)
  • PART C. WHAT FUTURE TOPICS ARE YOU INTERESTED IN TAKING?

    THIS HELPS US DEVELOP BETTER COURSES IN THE FUTURE (OPTIONAL)? Leave blank if you are not interested in courses in this area.
  • PART D. MOTIVATION (NOT OPTIONAL)

    THIS SECTION HELPS US TO EVALUATE IF YOU HAVE CHANGED AFTER TAKING THE COURSE?
  • PART E. TESTING YOUR WRITING SKILLS (NOT OPTIONAL)

    THIS SECTION HELPS US SEE HOW YOU WRITE.
  • Please respond in full (grammatically correct) sentences without assistance. 


  • Thanks for your time and assistance. Your input is helping us to better service you.


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