Parent/Caregiver Name*

First Last

Phone*

Email*

How many adults are attending?*

How many children are attending?*

What are the ages of the children attending? (Separate by commas)*

Are you currently enrolled in the Home Visiting Program?*

Yes
No
Unsure

Would you like more information about our FREE Home Visiting Program for families with children birth through age 5?*

Yes, please contact me
Maybe- I’d like to learn more at the event
No, thank you

How did you hear about this event?*

NATIVE HEALTH Home Visiting staff
NATIVE HEALTH clinic/provider
NATIVE HEALTH website or social media
Family or friend
Community partner/organization
Flyer/community event

Food Allergies (Please include Name of person, child/adult, and their allergy)*

Anything else you’d like us to know before the event?

I understand that I am signing up for an event. I agree to attend and receive text reminders from NATIVE HEALTH at the number provided related to this event, such as reminder texts. I understand that NATIVE HEALTH does not share phone numbers or information about users who opt-in to receive text messages. I understand that I can opt out at any time by replying STOP. My participation in this class is voluntary and I assume all risks, known and unknown. I also release and waive any claims for injury, illness, and any other damages that I may have against NATIVE HEALTH arising from my participation.*

Yes
No

Home Visiting’s 3rd Annual Ice Cream Social

Register below.

09-10-26 Home Visiting 3rd Annual Ice Cream Social

Details

Venue

NATIVE HEALTH Central

NHW Community Health Center

NATIVE HEALTH Mesa

NATIVE HEALTH at Walupe Health Center