Infant Safe Sleep Class Registration Form
The Natural Momma Me Initiative, 1pm In-person, 11000 W McNichols Rd Detroit 48221. Basement Conference Room A
Name
*
First Name
Last Name
What county do you live in?
*
Please Select
Wayne
Oakland
Macomb
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Which Class Would You Like To Attend?
*
Please Select
Wednesday, March 18
Thursday, March 19
How old are you?
*
Please Select
Under 18
19-24 years old
25-40 years old
41-55 years old
55+
I prefer not to answer
What is your gender identity?
*
Please Select
Female
Male
Nonbinary
What is your ethnic background?
*
Please Select
African American/Black
Hispanic
Arabic
White/Caucasian
Asian/Eastern
Native American
Multiracial
I prefer not to answer
What is your highest level of education you received?
*
Please Select
Eight Grade
High School
GED
College Degree
I prefer not to answer
What is your marital status?
*
Please Select
Married
Never Married
Divorced
Separated
Widowed
Domestic Partnership
I prefer not to answer
Do you have other children?
*
Please Select
Yes
No
How many children do you have?
*
Please Select
1
2
3
4
5
6
More than 6
Do you currently receive diapers/period supplies from The Natural Momma Me Initiative?
*
Please Select
Yes
No
Submit
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