BABY ALIVE SIGN UP

Full Name

First NameLast Name

Today's Date

MonthDayYearHourMinutesAM/PM Option

Welcome! M.E.N.T.O.R.S., Inc. is excited to present our new Baby Alive program. We will be facilitating support groups for young African American mothers and fathers, helping to celebrate births, providing a baby goods and diaper bank, and providing day care vouchers for low income African American families.

The purpose of this survey is to tailor the Baby Alive program to client needs. It should be noted that the program is geared towards ameliorating disparities in black infant and maternal mortality. Only low income participants who identify as black will be encouraged to enroll.

Address

Phone Number

Email address

What ethnicity do you identify as?

Date of birth?

Number of people in household?

Number of people in household under 18?

Number of children in household wearing diapers?

Number of children in household drinking similac or enfamil?

Are you interested in attending support groups?

Best day of the week for a support meeting?

Marital status

SingleMarriedDivorced

Are you interested in childcare assistance? Daycare etc.

Are you interested in mommy and me classes/play dates?

Employment?

Employed full-timeEmployed part-timeUnemployed

Are you currently in school?

Your education level? (high school, college, etc.)

Would you consider yourself or your family to be low-income?

Please list any other low-income assistance programs in which you are enrolled or have participated in within the past year.

What are your personal program goals?

M.E.N.T.O.R.S., Inc. Baby Alive Program Sign-up