Guest Registration
Prescott, 2025
Main Service
Day of Service
Please Select
Day 1
Day 2
Is this your first visit?
*
Yes
No-I was here yesterday
No-I was at a previous event
No-Second service today
Medical Records Number
*
You only need to type the last 4 numbers of the MR #. Example (2021-PV-0123): only enter 0123
Name
*
First Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address Type
Temporary
Permanent
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Language Choice
English
Spanish
Japanese
Chinese / Mandarin
Sign Language
Other
Gender
*
Male
Female
Other
Ethnicity
African American
Asian
Hispanic
Native American
White
Mixed
Other
Medical Services
A1C Testing
Anemia Check
B12 Shots
Blood Pressure Test
Blood Sugar Test
Chiropractic care
Diabetes Awareness
OB/GYN
Naturopath
Occupational Therapy
Pediatrics
Podiatry
Pregnancy Test
Primary Care
Physical Therapy
Sport Physicals
Strep Test
Well Women's Check
Wound Care
Other
Additional Services
Other Services
County Health
Hair Cuts
Healthy Living Counseling
Legal Counseling
Massage Therapy
Northland Cares
Request Prayer
Other
Where did you hear about AZ Sonshine
*
Church
Flyer/Mail
Food Pantry/Mission
Friend (Word of Mouth)
Internet
Local Business/Restaurant
Previous Event
Radio
Social Media (Facebook, Instagram...)
Are you a Client or AZ Sonshine Volunteer?
*
Client
AZSS Volunteer
Registration Volunteer’s Initials
*
Submit
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