Participate at Stepping Out, Inc.

In order for you to participate in our services, we first need you to please fill out this intake form. It helps us better understand you as a partner of Stepping Out.

Each field in the registration form with an asterisk (*) is required, so please be sure to fill them all in. Your application cannot be processed if you are missing any of the fields.

Once you have submitted your application, you will receive an email from Stepping Out that will direct you to register and pay for the classes that you want to attend. Please check your email after submitting this application.

Please note that by submitting this form you are acknowledging that the information you are submitting is accurate.

Thanks,
Stepping Out, Inc.

Personal Information
First Name *
Middle Name *
Last Name *
Home Phone *
Mobile Phone *
Home Address *
City *
State *
Zip Code *
Email Address *
Drivers License/Photo ID
Do you have a current drivers license or photo ID? *

Yes No
Driver's License / Photo ID Number *
Driver's License / Photo ID State *
Emergency Contact Information
First Name *
Last Name *
Phone Number *
Relationship to Emergency Contact *
Referral Information
Where were you referred?
If you selected "Other" above
Referral Name *
Referral Phone Number *
Goals & Objectives
What is your goal for participating with Stepping Out? *
Verification & Disclosures
Stepping Out, Inc. complies with the Health Insurance Portability and Accountability Act, (HIPPA), as developed by the Department of Health and Human Services. This law is designed to provide privacy standards to protect participants’ records and other health information. For your protection we require you to approve an authorization to disclose your attendance and participation information to referring and collaborating agencies. I approve information to be disclosed to referring and collaborating agencies. I understand that Stepping Out, Inc. is legally bound to inform authorities of any life-threatening case such as suicide, sexual or child abuse.
Check box for HIPPA authorization *

Yes
I give Stepping Out, Inc. (SOI) permission to use and otherwise publish, without charge or fees of any kind, the photographs, video or film, electronic recordings, commentaries, or testimonies of my by SOI or its agents. I understand that the photographs, film and video of me may be used by SOI in its news releases and advertisements, its publications, its printed material, and on its Web site, including but not limited to annual reports, brochures, educational and instructional materials, recruitment, illustrations, art, exhibits and displays. This includes the rights of sale, reproduction, use and distribution for any and all commercial benefit and purpose without limitation, in perpetuity, through the universe, in all media whether known or unknown. I understand that the photographs, video or film or electronic recordings of me, and all rights there in, including copyrights, are and shall remain the sole and exclusive property of SOI or its agent.
Check box for personal release authorization *

Yes
To my knowledge, the information submitted here is accurate and reliable to the best of my ability.
Check box for final authorization *

Yes
Today's Date *

"Stepping Out has been a wonderful place for me. It has provided me with Spiritual insight on many of life’s daily matters. I thank Stepping Out for all they do for the community and people. A lot of people receive help that they can’t get anywhere else. You have wonderful and caring people at Stepping Out. Keep doing what you’re doing because it works; it did for me. That’s why I give back to you my help."

Testimony

From J.S.