Bloom GBHE

BLOOM: Birthing Love Outreach & Optimal Motherhood

This is a 4-part series. The first session will be Saturday, August 29th from 11:00 AM to 1:00 PM at the Center for Black Women's Wellness at 477 Windsor Street SW Suite 309 Atlanta, GA 30312.
Your information is used for grant reporting purposes only and will be kept confidential with the Center for Black Women's Wellness.
Name

First NameLast Name
Are you currently or have you been a client of CBWW?
Date of Birth

MonthDayYear
Date
Email
example@example.com
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Which ONE racial classification do you identify with most?
If you Identify as Black or African American, please feel free to specify below.
Please specify below
Are you a parent?
If yes, what language do you speak at home?
Are you of Hispanic, Latino/a, or Spanish origin?
Do you speak a language other than English at home?
How well do you speak English?
What is the highest grade or level of school that you have completed?
Let us know if you are interested in any of the below CBWW services.
What Maternal Health Topics are you are interested in learning about?

Other
Do you need childcare? If so please share the number and ages of children
We will be offering light bites and snacks, do you have any dietary restrictions?
Should be Empty:

BLOOM: Birthing Love Outreach & Optimal Motherhood