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Celebrate Black Breastfeeding Week! Latch & Paint with Project Milk Mission August 31, 2024 - 11a.m.- 2 p.m.
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
Select Date to Attend
*
Please Select
August 31, 2024 (11:00 a.m. -2 :00 p.m.) Summit Lake Community Center, 380 W. Crosier St, Akron, OH 44311
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