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
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 NativeHispanicCaucasianEthiopianKurdishOther
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 momMom with ChildrenExpecting 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 19thJacksonville, FL - June 21stHollywood, FL/Broward County - June 22ndBoston, MA - September 14thPhiladelphia, PA - November 25thCharleston, WV - August 23rdLexington, KY - August 24thNashville, TN - October 11thSavannah, GA - October 12thGreenville, MS - November 8thMobile, AL - November 9thDallas, TX - November 15thEl Paso, TX - November 16th
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
PAMPER SIZE NEEDS:

Size 1 1–3 months 8–14 lbs
PAMPER SIZE NEEDS:

Newborn (NB) 0–1 month Up to 10 lbs
PAMPER SIZE NEEDS:

Size 2 2–6 months 12–18 lbs
PAMPER SIZE NEEDS:

Size 3 5–12 months 16–28 lbs
PAMPER SIZE NEEDS:

Size 4 18 months–3 years 22–37 lbs
PAMPER SIZE NEEDS:

Size 5 2–4 years 27+ lbs
PAMPER SIZE NEEDS:

Size 6 3–5 years 35+ lbs
PAMPER SIZE NEEDS:

Size 7 4+ years 41+ lbs
16. May we follow up with you and keep you informed about upcoming events and information?

Yes, Add Me to the THRIVE Moms & Dads Wellness Network!No
2. First Name
Should be Empty: