Please fill out the application below to get more information on bringing Authentic Connections Groups to your organization. "*" indicates required fields 1. First Name* 2. Last Name* 3. Phone*4. Email Address* 5. Organization Name* 6. Location (city, state)* 7. Occupation 8. Are you in a leadership position? Yes No 9. Why do you think Authentic Connections Groups might benefit you and/or your organization?*For organizations who can't afford the full price of $3600 per group of six participants, we offer a sliding scale fee. If you are in need of a reduced sliding scale fee in order for your organization to be able to participate in AC Groups, please check the box below. YES, I would like to request a sliding scale fee and further discuss pricing options to participate in AC Groups. NO, I would NOT like to request a sliding scale fee and am comfortable with the suggested donation of $3600 per each 12-session AC Group program consisting of six participants. Other 10. Is there anything else that you would like us to know?CommentsThis field is for validation purposes and should be left unchanged.