Program Enrollment | Empowered Bridge Institute

Your privacy matters. Please provide only information needed for enrollment. Do not enter Social Security numbers, immigration documents, medical records, detailed abuse history, or unnecessary case information.

Participant Information

Full name *

Preferred name

Email *

Phone numberOnly provide a number that is safe for us to use.

Preferred contact method *

May we leave a message?

Choose Your Program

Program *

Live Zoom DV Education Class — $35

Enrollment is confirmed after the $35 one-time program fee is received.

Pay $35 with Crowded

12-Hour DV Education & Community Advocacy Certificate — $80

Enrollment is confirmed after the $80 program fee is received.

Pay $80 with Crowded

40-Hour DV Insight & Victim Impact — Donation Supported

This educational offering is supported through donations to Empowered Bridge. Donations help support program materials, printing, administration, and educational access.

Support with a Crowded Donation

Payment method

Payment name or referenceOptional payer name or short reference so we can match payment to enrollment.

40-Hour Participant / Loved One Information

For the 40-hour program, the workbook PDF will be emailed to the loved one/requester for printing and mailing to the participant. Please do not enter detailed case information.

Participant full name *

CDCR / inmate number, if applicable

Facility name *

Facility mailing address

Loved one / requester name *

Email for workbook PDF *

Anything we need to know for workbook delivery?

Program Details

Preferred language

How did you hear about us?

Accessibility or participation needs

Consent & Program Terms

Important information

Empowered Bridge Institute provides educational and advocacy-focused programming and is not an emergency service, law firm, healthcare provider, or psychotherapy provider.
Participation does not create an attorney-client, therapist-client, or medical-provider relationship.
We cannot guarantee a court, employer, probation/parole agency, school, licensing body, or other third party will accept a certificate for a particular requirement.
Email and text messaging can carry privacy risks. Participants should use the safest contact method available to them.
Enrollment information is limited to program administration, communication, documentation, and legitimate organizational purposes.

I have read and understand the program information and consent to participate. * I consent to electronic communication using the contact information provided and understand ordinary email/text may not be fully confidential. * I confirm the information submitted is accurate to the best of my knowledge. * I understand I should not submit unnecessary highly sensitive information through this form. *