No Cost Back-to-School Health Services-Pre Registration
Event Date: Saturday, August 8th, 2026, 10am-1pm Location: Dominion International Center-Spring Church: 17800 Kuykendahl Rd. Spring, Tx 77379
Servicios de Salud Gratuitos para el Regreso a Clases: Registro previo
Fecha del evento: sábado, 8 de Agosto de 2026: 10am-1pm
What is your language preference? (¿Cuál es su preferencia de idioma?)
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English
Spanish (Español)
Other
Date of Birth (¿Fecha De Nacimiento?)
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Month
-
Day
Year
Fecha de Nacimiento
Age Range (¿Edad?)
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less than 18
19-25
26-35
36-45
46-55
56-55
66 and above
Name (Nombre)
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First Name (Nombre)
Last Name (Apellido)
Race (Raza)
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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
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Codigo de postal
County (Condado)
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Harris
Fort Bend
Montgomery
Waller
Liberty
Other
Phone Number (Número de teléfono)
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-
Area Code
Phone Number
Email (Dirección de correo electrónico)
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example@example.com
Parent/Guardian Information Number(if Under 18)
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Yes
No
If yes, display:
Parent/Guardian Name
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Relationship to Participant
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Parent/Guardian Phone Number
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Area Code
Phone Number
Acknowledgement
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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
Do you have health insurance? (¿Tienes seguro médico?)
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Yes, I have health insurance (Si tengo seguro medico)
No, I dont have health insurance (No tengo seguro medico)
Other
Consent & Acknowledgement
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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
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Date
*
-
Month
-
Day
Year
Fecha
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