The THRIVE Tour Registration Form

The THRIVE Tour Registration Form
The THRIVE Tour Registration Form
Please register for the THRIVE Tour by completing the form below. Note: Some locations may require you to wear a mask.
1. Email
example@example.com
2. First Name
3. Last Name
4. Phone Number
Please enter a valid phone number.
5. Gender

FemaleMaleNon-binaryOther
6. Age

18-2425-3435-4445+
7. Ethnicity

African AmericanNative American-Alaska NativeHispanicCaucasianOther
8. Explain Other (If you selected other for Ethnicity)
8A. Do you have a language interpertation requirement? If yes, please add language.
9. Registration Type (Mark only one.

Expecting momExpecting mom/person Military (active or veteran)Expecting DadDad with ChildrenGrandparentBirthing Professional (doula, midwife, aspiring doula)Healthcare Professional (doctor, nurse, social worker)
9A. Are you bringing guests (Dad, Grandmother or Children)?
10. I'm Attending:*

Brooklyn, NY - March 29thStaten Island, NY - March 30thLos Angeles, CA - May 17thSan Diego, CA - May 18thHouston, TX - April 19thEl Paso, TX - April 26thJacksonville, FL - June 21stMiami, FL - June 22ndBoston, MA - June 28thPhiladelphia, PA - June 29thCharleston, WV - August 23rdLexington, KY - August 24thFairbanks, AK - September 13thRapid City, SD - September 14thNashville, TN - October 11thSavannah, GA - October 12thGreenville, MS - November 8thMobile, AL - November 9th
11. Please enter your expected due date
12. Do you need prenatal healthcare?

YesNo
13. Are you interested in a Doula, Midwife, etc, support during pregnancy?

YesNoMaybe
14. Do you need Medicaid/health insurance coverage?

YesNo
15. Do you feel like your emotions are all over the place sometimes? Do you feel sad for long periods of time and need to speak to someone confidentially?

YesNoMaybe
16. May we follow up with you and keep me informed about upcoming events and information?

YesNo
Should be Empty: