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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.
This question requires a valid date format of MM/DD/YYYY.
calendar
This question requires a valid email address.
This question requires a valid email address.
This question requires a valid number format.
This question requires a valid date format of MM/DD/YYYY.
calendar
13. What is your gender?
14. Are you of Hispanic, Latino, or Spanish origin?
15. What is your race?
  • * This question is required.
16. What is your primary language?
17. Please select your highest level of education.
18. What is your marital status?
19. What is your insurance coverage?
Do you have a Medicare Advantage Plan?
 
20. Do you live alone? 
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
This question requires a valid number format.
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.