Solidarity Program Form | Ana Kica-Rosie

First name

Last name

Email

Phone

Briefly describe your current situation and challenge

What do you want to achieve for your well-being in three months?

Are you able to commit to a 45 minute session every two weeks for three months?

Yes

No

I understand this is a waitlist. Submitting this form does not guarantee a spot.

I understand

I respect your privacy. The information you share here is used only to evaluate your application for the Solidarity Program. I do not share your data with third parties.

I agree to the processing of my personal data for the purpose of this application