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Healthy Living Spring 2022 Enrollment

Registration questions

Thank you for taking a few minutes to answer some brief questions on this registration form and survey. The information you provide helps us demonstrate who we are serving and the benefits of the program. It also helps us improve our services.
Please note: Class enrollment is first come, first served. Completing this form does not guarantee your spot in the workshop

1. Name *This question is required.

First
Last

2. Email address *This question is required.

3. Phone number *This question is required.

4. Mailing address (for materials to be sent to)

Address
City
Zip code

5. Date of birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

6. Sex

7. How did you learn about this workshop?

8. Are you Hispanic, Latino or Spanish origin?

9. What is your race?

American Indian or Alaskan Native
Black or African American
White or Caucasian
Asian
Native Hawaiian or other Pacific Islander
Other - Write In Please enter an 'other' value for this selection.

10. What is the highest grade or year of school you completed?

11. Has a health care provider ever told you that you have any of the following chronic conditions? (Check all that apply.)

12. In the past three months, how many times did you go to a hospital emergency room for your own care related to a chronic condition? This question requires a valid number format.

13. In the past three months, how many times did you stay in a hospital overnight or longer related to a chronic condition? This question requires a valid number format.

14. What is your health insurance coverage?

Please enter an 'other' value for this selection.