Back to School Lead Form 2024

Please complete this form to redeem your free backpack voucher.

Once you hit "submit" your voucher will be on the following screen.
Name*
Which Adelante Healthcare location do you plan to visit?*
Email*
example@example.com
Phone Number*
By checking the box below, you consent to receive marketing and promotional emails and texts from Adelante Healthcare.*

I consent.
By checking the box below, you acknowledge that you have read and agree to the terms and conditions of this promotion: "Terms and conditions apply. While supplies last. 1 backpack per school-aged child that completes a well-child check. Only valid between the dates of July 15th, 2024 - August 16th, 2024. This voucher does not guarantee a backpack."*

I have read and agree to the terms and conditions.
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Please complete this form to redeem your free backpack voucher.