Jericho Walk/CHECK Participant Registration Form

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THANK YOU SO MUCH FOR COMING!!!!!! please take a moment to fill out our registration form to receive FREE Food and School Supplies while they last!!!

Date:

Participant Name (First, Last)

Address:

City:

Zip code:

Telephone:

Age?

Under the age of 17

18- 25

26-55

56 and above

Clear selection

Did you walk in our parade?

Yes

Clear selection

How did you hear about this Festival/Health Fair?

I recieved an Email

I received a SMS/Text from the CHECK program

I was told by a Community Health Worker

I recieved a Flyer

I received a Phone call

I was told by a friend

I was told by my provider

Other

Have you ever been to a Jericho Walk Festival before

Yes

Clear selection

Today, I am looking forward to receiving more information or services regarding:

Asthma

Sickle Cell

Premature babies

Mental Health

Diabetes

Dental Van

Community Resources and Social Services

School Supplies

Free Food

Free Concert

College Scholarships

Other:

Do you have a community health worker (CHW) assigned to you?

Yes

I don't know

Clear selection

How would you like to hear about upcoming events?

I would like to receive an email

I would like to receive a text

I would like to be told by a Community Health Worker

I would like to receive a flyer

I would like to receive a phone call

I would like to recieve information from my friend

I would like to recieve information from my provider

I would like to recieve information at my church

Are you in need of church home or faith-based services?

Yes

Clear selection

If No, What church or faith-based institution do you belong to?

Data entry staff

Submit

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