Registration Form

Registration Form

What class are you registering for?

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Name*

DOB*

Address*

City*

State*

Zip Code*

Patient Race

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Patient Ethnicity

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Primary Language

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Patient Gender

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Primary Care Provider Name

Do You Have Insurance Coverage?

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Most Recent A1C

Most Recent BP

Do you smoke or use tobacco products?

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All Questions below are optional

Housing in the last 12 months

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Transportation in the last 12 months

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Food in the last 12 months

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How often do you need help with reading?

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Within the last year have you

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How often do you engage in moderate exercise?

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Do you feel any of the following?

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How often to you see/talk to friends & family?

How often do you have a drink containing alcohol?

When drinking, how many drinks do you consume?

For more information on REACH Programs, please visit

https://www.healthydelmarva.org/tiles/index/display?id=310296390956302321

This activity is part of the Rural Equity and Access to Community Health (REACH) program and is funded by TidalHealth through a grant from the Maryland General Assembly as part of the Maryland Health Equity Resource Act. Grant funding is administered by the Maryland Community Health Resources Commission. For more information, please visit: https://health.maryland.gov/mchrc/Pages/herc.aspx. The views presented here are those of the grantee organization and not necessarily those of the Commission, its Commissioners, or its staff

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