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Black Maternal Health Week 2024
Register for Virtual and/or In-Person Events
Name
*
First Name
Last Name
Date of Birth
*
Race/Ethnicity
*
Please Select
White
Black or African American
Hispanic or Latino
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other
Unknown
Address
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Status
*
Pregnant
Postpartum
Other
Due Date
-
Month
-
Day
Year
Date
Are you currently enrolled in Ohio Medicaid?
*
Yes
No
Pending
If enrolled in Medicaid, please provide your Medicaid ID number (This is a 12 digit number).
Insurance Provider?
*
Please Select
Buckeye Health Plan
Care Source
Molina Health Care
Paramount Advantage
United Health Care Community Plan
Traditional Medicaid
Other
Non-Applicable
Are you currently receiving any breastfeeding services/support?
*
Yes
No
Trimester of your first prenatal visit
Please Select
1st Trimester
2nd Trimester
3rd Trimester
Number of other children in the home
Please Select
1
2
3
4
5
6
7
8
9
10
Do you have a Medical Home (e.g. OBGYN, Primary Care Physican)
Please Select
Yes
No
Other
Select date to attend the class
*
Please Select
April 11, 2024 5:30 p.m.-7:00 p.m. Virtual Self-Care and Breastfeeding class.
April 13, 2024 12pm-3pm Self-Care and Breastfeeding event: Location 532 W. Market St, Akron, 44303
April 15, 2024-12:30pm-2:00pm Infant Feeding Cooking Class: Location 350 Opportunity Pkwy, Akron, 44307
Are you interested in scheduling a lactation consultation?
Please Select
Yes
No
Additional Information (e.g. interpreter needed/language spoken)?
Are there any other resources you need help connecting with?
How did you hear about Project Milk Mission?
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