Caregiver Interest Form

Are you someone who takes full care and responsibility for others? A mother, wife, who may or may not have a full-time job, but is the sole caregiver for a family member, a friend, or a neighbor. You could also be a Teacher who goes overboard to equip your students with inspiration, the tools to success, and extends personal care daily. Or perhaps your job as a Nurse, CNA, Home Health Care, EMT, Therapist, Coach, etc.; those of you who carry the care for others on your shoulders daily.

GirlTREK recommends practicing self-care on a daily basis. If you are not on a self-care journey, we hope that you get on board NOW! Please answer each question to the best of your ability, taking care to elaborate where needed.

SELF-CARE IS A REVOLUTIONARY ACT! Thank you.

First Name *

Last Name *

Phone

Email *

City

State/Province

Postal Code

Are you a Caregiver?

Who do you primarily care for? (Select all that apply)

Birthing Mothers

Children

Elderly parents or relatives

Disabled family member

Community (i.e. teacher, nurse, social worker, etc.)

How many hours per week do you typically spend caregiving?

What kinds of support or resources would be most helpful for you?

Are you interested in leading the self-care movement for Caregiving women?

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