No Cost Back-to-School Health Services-Pre Registration
Event Date: Saturday, July 25, 2026, 8am-12pm Location: PowerHouse Church: 1818 Katyland Dr, Katy, TX 77493
Servicios de Salud Gratuitos para el Regreso a Clases: Registro previo
Fecha del evento: sábado, 25 de Julio de 2026: 8am-12pm
What is your language preference? (¿Cuál es su preferencia de idioma?)
*
English
Spanish (Español)
Other
Date of Birth (¿Fecha De Nacimiento?)
-
Month
-
Day
Year
Fecha de Nacimiento
Age Range (¿Edad?)
*
less than 18
19-25
26-35
36-45
46-55
56-55
66 and above
Name (Nombre)
*
First Name (Nombre)
Last Name (Apellido)
Race (Raza)
*
American Indian or Alaska Native (Indio Americano o Nativo de Alaska)
Hispanic or Latino
Black/African-American (Afroamericano)
Middle Eastern or North African (Oriente Medio o África del Norte)
Native Hawaiian or Pacific Islander (Nativo de Hawái o otra Isla del Pacífico)
White (Caucásico)
Unknown (Desconocido)
Asian (Asiático)
Other
Zip code
*
Codigo de postal
County (Condado)
*
Harris
Fort Bend
Montgomery
Waller
Other
Phone Number (Número de teléfono)
*
-
Area Code
Phone Number
Email (Dirección de correo electrónico)
*
example@example.com
Parent/Guardian Information Number(if Under 18)
*
Yes
No
If yes, display:
Parent/Guardian Name
*
Relationship to Participant
*
Parent/Guardian Phone Number
*
-
Area Code
Phone Number
Acknowledgement
*
I understand that participants under the age of 18 must be accompanied by a parent or legal guardian at the event.
Which services are you interested in receiving? (Select all that apply): Mobile Aetna/CVS Unit
Body Mass Index
Blood Pressue Screening
Glucose Screening
Total Cholesterol Screening
Individual Health Access Plan
Professional Consultation
Smoking Cessation Counseling
Diabetes Resources
Houston Health Department
Vaccines
Vaccination Information: Do you have a copy of your vaccination/shot record?
Yes, I will bring it
No, I do not have it
Unsure
If requesting vaccinations, please select:
Child Immunizations
Adult Immunizations
Back-to-School Vaccination
Not sure
Vaccination Record Notice: If you do have your vaccination record, we may be able to locate your immunization history through the state immunization registry if previous vaccines were reported.
*
Yes, acknowledged
Harris County Public Health Mobile Unit
Family Planning Services
Breast and Cervical Screenings
Sport Physicals
Maternal & Child Health Services
Sport Physical Requirements: Are you registering for a Sports Physical?
Yes
No
Do you have the Sports Physical Form?
Yes, I will bring it.
No, I need to obtain one
Unsure
Sport Physical Acknowledgement
*
I understand that I must bring the required Sports Physical Form to the event.
I understand that participants under 18 years of age must be accompanied by a parent or legal guardian.
I understand that failure to bring the required Sports Physical Form may delay or prevent completion of the Sports Physical.
Do you have health insurance? (¿Tienes seguro médico?)
*
Yes, I have health insurance (Si tengo seguro medico)
No, I dont have health insurance (No tengo seguro medico)
Other
Consent & Acknowledgement
*
I understand that form is a pre-registration form and does not guarntee services.
I understand that participants under 18 years of age must be accompanied by a parent or legal guardian.
I understand that I should bring my vaccination/shot record if available.
I understand that my insurance information is self-reported.
Signature
*
Date
*
-
Month
-
Day
Year
Fecha
Should be Empty: