Sponsorship Eligibility Questionnaire
Submit the answers to this questionnaire and we can tell you if you qualify for a sponsored membership.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Preferred Email
*
example@example.com
Address
*
Street Address
City
State / Province
Postal / Zip Code
What is your date of birth?
*
How old are you?
*
How many times have you been pregnant?
*
Please Select
1
2
3
4
More than 4
Did you deliver before 36 weeks in any of your pregnancies?
*
Please Select
Yes
No
Have you had any C-Sections?
*
Please Select
Yes
No
If so, how many?
Please Select
1
2
3
More than 3
Did you have any complications in your prior pregnancy? (example: hypertension, pre-eclampsia, bleeding, diabetes, blood clot)
*
Please Select
Yes
No
Do you have any mental health issues? (example: depression, anxiety)
*
Please Select
Yes
No
Are you African American?
*
Please Select
Yes
No
What is your first language?
*
Please Select
English
Spanish
Other
Do you qualify for Medicaid?
*
Please Select
Yes
No
What is your household income?
*
Please Select
less than $10,000
$10,000 - $29,999
$30,000 - $39,999
$40,000 - $49,000
$50.000 - $59,000
$60,000 - $69,999
$70,000 - $79,999
$80,000 -$99,999
Over $100,000
Do not want to comment (I realize this may affect my sponsorship)
What is your current household size?
*
Please Select
1
2
3
4
5
more than 5
Do you have insurance?
*
Please Select
Yes
No
I hereby certify that, to the best of my knowledge, the provided information is true and accurate.
*
Please Select
Yes
No
Signature
*
Date
-
Month
-
Day
Year
Date
Type Name
First Name
Last Name
Submit
Submit
Should be Empty: