A Better Me Registration

A Better Me! Registration
Sign up for an upcoming cohort!

Please be sure to sign up for our next cohort! With an emphasis on Healthy Babies, Moms & Families, the Mothers Cove: A Better Me is a 6-week program (one session per week), with each session held from 6:00 PM – 8:00 PM at First Church of God, 3480 Refugee Rd., Columbus, OH 43232. For more information visit www.corgoodlifefoundation.org/mothers-cove or please contact Jackie Flemings at jackie@corgoodlifefoundation.org.
Which Start Date are you registering for?*

January 29, 2026October 15, 2026
Mother's Name*

First NameLast Name
Parent/Guardian/Custodian Email
example@example.com
If you are currently pregnant, what is your due date? If you are not pregnant, when did you give birth?*
Your Race*

Black or African AmericanWhiteAmerican Indian or Alaska NativeAsianLatinoNative Hawaiian or Other Pacific IslanderOther
Mother's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Father/Guardian/Custodian Name

First NameLast Name
Father's Email
example@example.com
Father's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you a U.S. Citizen?*

YESNO
Family Household and Income

Using the chart below, determine if the household income is at or below 200% of the 2019 Federal Poverty Level limits. Select the applicable household family size and monthly income that matches the income status for the applicant family.
Number of household members*
Is the family's total income at or below 200% of the Federal Poverty Level based on household size?*

YesNo
How many kids might be with you for childcare?
Leave blank if you'll not need Childcare
Children in Household
Name

First NameLast Name
Age
Name

First NameLast Name
Age
Name

First NameLast Name
Age
Name

First NameLast Name
Age
How did you hear about the upcoming Mothers Cove cohort?

Social MediaPostal MailWebsiteWord of Mouth
Comments
Self Attestation*

I certify to the best of my knowledge, the information included in this application is true, including income and citizenship/qualified non-citizenship information.
Parent/Guardian/Custodian Signature*
Date*

MonthDayYear
Date
Should be Empty:

A Better Me! Registration

Sign up for an upcoming cohort!

Children in Household