HeartStrong Network Enrollment

Name

Address

All information submitted for inclusion in the HeartStrong Network is held in 100% confidence. The information will not be sold, rented, loaned or viewed by any other organization. This information is stored and transmitted to a secure place.

Thank you for your participation!

Information provided to HeartStrong via email, telephone, mail or by registering with the HeartStrong Network is viewed only by persons working directly with HeartStrong unless you check the "yes, share my story" button on the HeartStrong Network registration page.

City State Zip

Telephone Email

Schools you attended (full names, city and state) If the school's denomination affiliation is not in the school name, please include. Also, include the years you attended each school next to the school name.

Did you graduate? Yes No

Were you disciplined for being GLBT? Yes No

Were you expelled for being GLBT? Yes No

Did you know of others who were disciplined or expelled? Please share their experiences here.

May we share your personal story on our website and in other HeartStrong publications?

Yes No

Use the space below to share more of your personal experiences.

Would you like an invitation to join our HeartStrongEmail List?

Yes No

Please consider making a one-time tax-deductible donation or an ongoing pledge to help support the life giving work of HeartStrong.

Please choose one: Monthly One-Time

$10.00 $25.00 $50.00 $75.00 $100.00

Other:

HeartStrong Accepts Visa/MasterCard/Discover cards for

donations. Please enter your account information below.

Card #

Expiration Date (00/00)

3 Digit Security Code from back of Card

Name on card

Billing Address Zip Code

Telephone Number * (required)

Email Address * (required)

May we list you as a donor? Yes No

Notes regarding your donation: