Event Registration
Please complete one registration form per household.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you a Kern Family Health Care member?
Yes
No
What's your zip code?
*
(Ex: 93301, 93307, etc.)
Age Range
10-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
Race/Ethnicity
American Indian or Alaska Native
Asian
Black or African American (Non-Hispanic)
Hispanic or Latino
Middle Eastern or North African
White (Non-Hispanic)
Native Hawaiian or Another Pacific Islander
Other
How many people will attend with you, including yourself?
*
Please list each Additional Registrant below, if any.
Rows
First Name
Age
KFHC Member? (Yes or No)
Registrant #1
Registrant #2
Registrant #3
Registrant #4
Registrant #5
What are you most interested in gaining from this workshop?
Managing holiday stress
Building stronger family relationships
Mental wellness strategies
Youth emotional wellness
Coping skills
Family communication
Community resources
Fun family activities
Meeting other families
Other
Beyond the Stars No Limits may take photographs or video during the event for community outreach, program documentation, social media, reports, and promotional purposes. Do you give permission for you and/or the minor children you are authorized to register to appear in photographs or video? Declining photography will not affect your ability to attend.
*
Yes, I give permission.
No, I do not give permission.
Disclaimer
Bright Minds, Warm Hearts is a community wellness and educational event designed to provide information, resources, and family-centered activities. This event does not provide mental health treatment, crisis intervention, diagnosis, or medical care and is not a substitute for services from a qualified healthcare or mental health professional. By signing below, you acknowledge that you have read and understand this disclaimer.
Signature
Registration Confirmation
*
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