Community Wellness & Literacy Fair 11:00 am-3:00 pm5411 Pardee St.Houston, Texas 77026

Community Wellness & Literacy Fair

11:00 am-3:00 pm

5411 Pardee St.

Houston, Texas 77026

Location: McCrane Kashmere Gardens Library

February 8, 2025

Last Name/Apellido*

First Name/Primer nombre*

Middle Initial/Segundo nombre

Address/Direccion*

Apt number/Numero de apartamento

City/Ciudad*

Zip Code/Apartado postal*

Email address/Correo electronico

Phone Number/Numero de telefono

Ethnicity/Etnia*

Hispanic or Latino

Not Hispanic or Latino

Race/Raza*

White

Hispanic or Latino

American Indian/Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

Other

Preferred Language/Lenguaje preferido

Gender/Genero*

Date of Birth (needed for service eligibility)*

Fecha de nacimiento

Reason for Attending/Motivo por su asistencia

How many people are with you?

¿Cuantos personas estan contigo?

Do you have a Primary Care Physician?

¿Tienes un doctor primario?

Yes

No

Insurance/Aseguranza

Insurance (Private)

Insurance (Medicare)

No Insurance

Harris Health (Gold Card)

Other

How did you hear about this event?

¿Como escuchaste de este evento?

Do you want to be notified of future events?

¿Quieres ser notificado para futuros eventos?

Yes

No

Date of Event

Send me a copy of my responses

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