Participant Registration Form - Her Wellness Collective

Participant Registration Form -Her Wellness Collective

Please fill out your personal, health, and consent information to register for the program.
This program is sponsored by the Mississauga Foundation — Novo Nordisk Chronic Disease Fund.
Confidentiality Statement: All responses will be kept confidential, stored securely by Care Masters Women and Family Services, used only for program evaluation and reporting purposes, and shared with funders only in aggregate summary form.
I have read and understand the confidentiality statement
First Name
Last Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender

Other
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Program Eligibility

Please answer the following eligibility questions.
Do you currently live in the Greater Toronto Area (GTA)?

Other
Do you identify as a Black woman?
Ethnicity

Other
Primary Language Spoken
Which barriers have affected your health in the past year?

Other
How did you hear about the program?
Which of the following apply to you?

Other
Do you have access to a Primary Care Provider (family doctor or nurse practitioner)?
If you have a family doctor or nurse practitioner, how well do they meet your health needs? Please tell us about your experience
What are your main health goals?
Do you have any physical activity limitations?
Please list any dietary restrictions or allergies
I give permission for my photo or video to be taken and used for program purposes.
Program commitment
Age Group
Should be Empty:

Participant Registration Form -Her Wellness Collective

Program Eligibility