Rooted in Freedom, Flourishing in Health – Community Check-In
We’re glad you’re here. This quick check-in helps us better understand who we’re serving and how we continue to bring the right resources to our community.
Name (Optional)
First Name
Last Name
Age Range
Please Select
Under 18
18–24
25–34
35–44
45–54
55–64
65+
Email
example@example.com; For event updates and resources only
Zip Code
This helps with reporting + funding + impact
What brings you out to the community health fair?
Health screenings
Mobile clinic services
Health education/seminars
Supporting someone else
Just stopping by / curious
Other
What services are you interested in receiving?
Diabetic eye screening
Urgent care screening
General health screening (mobile clinic)
Health seminars
Mental health resources
Financial / wellness resources
Have you attended a Juneteenth GVL event before?
Yes
No
Would you like to stay connected with Juneteenth GVL?
Yes
No
Submit
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