Earth Day Celebration at CBWW
Full Name
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First Name
Last Name
Phone Number
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Format: (000) 000-0000.
E-mail
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example@example.com
What is your gender?
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Female
Male
Non-binary
Declined to Answer
What ONE race do you identify with most?
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Black or African American
Asian
White/Caucasian
Native Hawaiian
Native American
Pacific Islander
Declined to Answer
Other
What is your ethnicity?
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Hispanic or Latino
Not Hispanic or Latino
Don't Know
Decline to answer
Year of Birth
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Have you been a CBWW client, patient, or participant before? Please select all that apply.
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No. I have never been a CBWW client, patient, or participant before.
Yes, I am a current client.
Yes, I am a former client.
If you are a current or former client, please indicate which programs you have been a part of.
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Wellness Clinic or Primary Care Clinic
Breast and Cervical Cancer Program (Example: Vision Board Workshops)
Behavioral Health Program (Example: yoga, Zumba)
Atlanta Healthy Start Initiative (pregnancy and parent-and-baby program)
COVID-19 Vaccination and Education
If you are bringing any family members with you, what are their ages?
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Ages 0-5
Ages 6-12
Ages 13-18
Ages 19-25
Ages 26-55
Ages 55+
How did you hear about this event?
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Social Media (Facebook, Instagram, Twitter, etc.)
Criado
CBWW Staff
CBWW Email Newsletter
CBWW Website
Clinic/Healthcare Agency
Community Based Organization
Community Event
Friend/Relative
Flyer/Postcard
Grady Hospital
Newspaper/Magazine
Radio
Outreach Team
Optional: Let's us know what you are interested in and we will follow up with you!
Healthcare -Primary Care, Gynecology, STI Testing
Mammograms Healthcare (Breast Cancer Screening)
Behavioral Healthcare -Counseling, Psychiatry
Health Education/Seminars
Entrepreneurship/Financial Literacy
Prenatal & Parenting Support (Pregnant or Mother with Children Under 18 months-Fulton County Residents Only)
Fatherhood Support (Having a Baby or have Children Under 18 months - Fulton County Residents Only)
Are you currently pregnant?
Yes
No
At this Earth Day Celebration, the Center for Black Women's Wellness and our various other visiting vendors will be giving out free items including cleaning products that contain ingredients that may cause allergic reactions or other health concerns. Do you understand that CBWW or our visiting vendors will not be responsible for any harm caused by the giveaways?
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Yes, I understand.
There will be photography at this event to capture great community memories and to share with our funders to help us continue providing the community with amazing events and resources.
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Yes, I understand
Compudopt Computer Giveaway
In honor of Earth Month, we invite your community members to bring in any old devices for donation—laptops, tablets, and more! Let’s work together to reduce e-waste and make a positive impact on our planet. REGISTRATION FOR FREE COMPUTERS HAS CLOSED.
Would you like a free laptop from Compudopt at the Earth Day Celebration?
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Yes
No
Names will be chosen randomly based on the available inventory 3-days prior to distribution dates. To qualify, you must not have access to a working computer at home, and you must have a child in pre-K-12 education (up to age 26). Devices provided by the school should not be counted as they are not owned by the family. Selected recipients will be notified by email and/or text message to complete the RSVP process and instructions on next steps!
I do not have access to a working computer at home
I have a child in pre-K-12 education (up to age 26)
Registering does not mean I am getting a laptop. I must be invited 3 days prior to the event.
Please note that the last day to register is Monday, April 13th.
First, submit this Earth Day Registration form. Then, copy and paste this link to register with Compudopt --> https://www.compudopt.org/atlanta-wifi
Submit
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