Wufoo
2024 -Prenatal Session Registration
Please complete the registration form
First and Last Name
*
First
Last
May we have a textable number
*
###
-
###
-
####
Are you currently pregnant?
*
Yes
No
When is your estimated DUE date?
*
MM
/
DD
/
YYYY
What is the MONTH of your birthday?
*
Day of your Birthday
*
Enter
1
to
31
digits.
Currently Used:
0
digits.
If you are currently expecting how far along are you?
*
Not sure
0 - 3 months
4 months
5 months
6 months
7 months
8 months
9 months
What is your ZIP code? enter-5 digit code; for example, 00544 or 94305
May we have an email address for future contact
*
What is your age range?
*
17 or younger
18 - 20
21 - 29
30 - 39
40 - 49
What is the highest level of school you have completed or the highest degree you have received?
*
Less than high school degree
High school degree or equivalent (e.g. GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
Which one of the following best describes your current relationship status?
Married
Single
Divorced
Will this be your first baby?
*
Yes
No
N/A
Do you have children in your household 12 months or younger?
Yes
No
What is your ethnicity? (Please check all that apply)
*
American Indian or Alaskan Native
Asian or Pacific Islander
Black or African American
Hispanic or Latino
White/Caucasian
Prefer not to answer
Other
Are you currently formula feeding?
Yes
No
Are you currently breastfeeding?
*
Yes
No
Where do you plan to deliver? Which hospital? Home birth? Other?
Do you currently receive WIC benefits?
Yes
No
Which if any is your current health care plan?
*
Buckeye Health Plan
CareSource
Molina
Paramount
United Healthcare Community Plan
Private Health care insurance thru an employer
Other
How many prenatal visits have you completed to date?
*
1 - 2 prenatal visits
3 - 5 prenatal visits
6 - 7 prenatal visits
8 or more prenatal visits
N/A
Are you currently employed outside the home?
*
Not employed
Employed full time
Employed part time
Currently a student
Disabled
If this is not your first pregnancy, how many other live births have you had?
*
1 - 2
3 - 4
5 or more
N/A
Please select ONE day and time you would like to attend a BOOBS session
Friday January 12, 2024 Virtual @ 10:30 am
Friday January 19, 2024 Virtual @ 10:30 am
Wednesday January 24, 2024 @ 6:30 pm
Friday January 26, 2024 Virtual @ 10:30 am
Monday January 29, 2024 @ 6:30 pm
Wednesday January 31, 2024 @ 6:30 pm
Friday February 2, 2024 Virtual @ 10:30 am
Friday February 9, 2024 Virtual @ 10:30 am
Friday February 16, 2024 Virtual @ 10:30 am
Monday February 19, 2024 @ 6:30 pm
Wednesday February 21, 2024 @ 6:30 pm
Friday Februray 23, 2024 Virtual @ 10:30 am
Monday Febrary 26, 2024 @ 6:30 pm
Wednesday February 28, 2024 @ 6:30 pm
Friday March 1, 2024 Virtual @ 10:30 am
Wednesday March 6, 2024 In person @ 6:30 pm
Friday March 8, 2024 Virtual @ 10:30 am
Monday March 11, 2024 in person @ 6:30 pm
Wednesday March 13, 2024 in person @ 6:30 pm
Monday March 18, 2024 in person @ 6:30 pm
Friday March 22, 2024 Virtual @10:30 am
Monday March 25, 2024 in person @ 6:30 pm
Wednesday March 27, 2024 in person @ 6:30 pm
Wednesday April 3, 2024 in person @ 6:30 pm
Monday April 8, 2024 in person @ 6:30 pm
Wednesday April 10, 2024 in person @ 6:30 pm
Friday April 12, 2024 Virtual @ 10:30 am
Monday April 15, 2024 in person @ 6:30 pm
Wednesday April 24, 2024 in person @ 6:30 pm
Monday April 29, 2024 virtual @ 6:30 pm
Wednesday May 1, 2024 virtual @ 6:30 pm
MOTHERS DAY SESSION IN PERSON MAY 9, 2024 @ 6:30 PM **
Monday May 13, 2024 in person @ 6:30 pm
Friday May 17, 2024 virtual @ 10:30 am
Monday May 20, 2024 in person @ 6:30 pm
Friday May 24, 2024 virtual @ 10:30 am
Friday May 31, 2024 virtual @ 10:30 am
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