Maternal & Infants Service Providers Meeting (Hattiesburg) Registration Form
Courtyard Marriott Meeting Room, Hattiesburg, Mississippi
About this Meeting:
Join us for the Mothers & Infants Service Providers Meeting, a gathering of organizations, clinics, and businesses working to support healthy outcomes for moms and babies across Mississippi. This meeting will help us build stronger connections, share resources, and improve collaboration among service providers. Please complete the form below to register your organization or business.
Full Name
*
First Name
Last Name
Agency/Organization
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Organization Type (Select all that apply):
Community-based organization
Health Clinic or hospital
Early childhood or childcare provider
Faith-based organization
Government Agency
Business or social enterprise
Other
Services Provided (Select all that best describe the services your organization provides):
Maternal health or prenatal care
Infant or child health services
Mental health or counseling
Nutrition or breastfeeding support
Housing or family resources
Workforce or parent education
Advocacy or policy work
Other
Do you accept Medicaid eligible clients?
Yes
No
Please list any accessibility needs or dietary restrictions:
What are you hoping to gain from this meeting?
Would you like to join our provider network or email list for future collaborations?
Yes, add me to network
No, just to this meeting
Submit
Should be Empty: