A Better Me Registration

A Better Me2! Registration

An online cohort to Healthy Moms, Healthy Babies, Healthy Outcomes!
Be sure to sign up for an upcoming cohort!

The first step to a Healthy Babies, Moms & Families...online! 4 sessions, 1 session per week. Each session runs 10:00am - 12:00pm. A link will be sent out to join before the first online cohort. For more information visit www.corgoodlifefoundation.org/mothers-cove or call 1-614-338-8338.
Reserve your spot in our next virtual cohort, starting in 2026!
- March 7, 2026
- May 16, 2026
A meeting link will be sent to your email as the start date approaches.
Which Start Date are you registering for?*

March 7, 2026May 16, 2026
Mother's Name*

First NameLast Name
Parent/Guardian/Custodian Email*
example@example.com
Are you Pregnant? If so, what is your due date?*
Your Race*

Black or African AmericanWhiteAmerican Indian or Alaska NativeAsianLatinoNative Hawaiian or Other Pacific IslanderOther
Mother's Phone Number*
Please enter a valid phone number.
Father/Guardian/Custodian Name

First NameLast Name
Father's Email
example@example.com
Father's Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you a U.S. Citizen?*

YESNO
Family Household and Income

Using the chart below, determine if the household income is at or below 200% of the 2019 Federal Poverty Level limits. Select the applicable household family size and monthly income that matches the income status for the applicant family.
Number of household members*
Is the family's total income at or below 200% of the Federal Poverty Level based on household size?*

YesNo
Children in Household
Name

First NameLast Name
Age
Name

First NameLast Name
Age
Name

First NameLast Name
Age
Name

First NameLast Name
Age
How did you hear about the upcoming Mothers Cove cohort?

Social MediaPostal MailWebsiteWord of Mouth
Comments
Self Attestation*

I certify to the best of my knowledge, the information included in this application is true, including income and citizenship/qualified non-citizenship information.
Parent/Guardian/Custodian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

A Better Me2! Registration

Be sure to sign up for an upcoming cohort!

Children in Household