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Health Self-Management Program

Welcome to our registration survey. Thank you in advance for your time and input.All information requested in this form is used to support this community program. Asterisks mark questions or fields where answers are required. Otherwise, you may leave some questions blank if you are not comfortable answering.

Which program are you interested in attending? *This question is required.

1. Class code: *This question is required.

What is the start date for the class you are interested in attending? *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

2. First name *This question is required.

3. Last name *This question is required.

4. Street Address *This question is required.

5. City *This question is required.

6. State *This question is required.

7. Zip Code *This question is required.

8. County *This question is required.

9. Email Address This question requires a valid email address.

10. Verify email address This question requires a valid email address.

11. Phone Number *This question is required. This question requires a valid number format.

12. Date of Birth *This question is required.

13. What is your gender?

14. Are you of Hispanic, Latino, or Spanish origin?

15. What is your race?

American Indian or Alaska Native
Asian or Asian-American
Black or African American
Hawaiian Native or Pacific Islander
White or Caucasian
Other Please enter an 'other' value for this selection. * This question is required.

16. What is your primary language?

Please enter an 'other' value for this selection.

17. Please select your highest level of education.

18. What is your marital status?

19. What is your insurance coverage?

Medicare
Medicaid
Private Insurance
Veterans Benefits
None
Other - Write In (Required) Please enter an 'other' value for this selection.

Do you have a Medicare Advantage Plan?

Who is your Medicare Advantage Plan Provider?

20. Do you live alone?

How many people are in your household, including yourself? This question requires a valid number format.

21. During the past year, did you provide regular care or assistance to a friend or family member who has a long-term health problem or disability?

22. Emergency Contact Information

Name

Phone Number This question requires a valid number format.

Relationship

23. Please indicate your monthly income. If you are married, please indicate the income that best represents your combined monthly income. This question requires a valid number format.

24. I am a Veteran.

25. I have a family member on active military duty.

26. Would you like to be contacted about future health care education classes or events?

Preferred method of contact

27. Did your doctor, nurse, physical therapist, or other health care provider suggest that you take this program?

28. Do you have a primary care doctor or health care provider?

Please list health care provider information.

Name
Phone Number