Black Maternal Health Week Registration Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We are excited to share the Los Angeles County Black Maternal Health Week: "Our Bodies Belong to Us: Restoring Black Autonomy and Joy!" with you all! We will be providing gift baskets. Please take a few minutes to fill out the form to get a sense of who you are and how we can better serve you.

Fathers, Mothers, Moms-To-Be, Grandparents are all welcome!

Date/Time: Friday, April 14th, 2023, from 12 pm - 3 pm

Location: The African-American Museum of Beginnings

1460 E Holt Ave Suite 188

Pomona, CA 91767

If you have any questions, please contact our backbone agency, YWCA-SGV's Equity & Social Justice Specialist, Jacqueline Hasty at (626) 201-6731or by email at jacquelinehasty@ywcasgv.org . Thank you!

For the day of assistance, don't hesitate to contact SGV AAIMM Community co-lead Carla Michael at (909) 480-1998

First & Last Name *

Email Address *

Zip Code *

What is your age? *

17 years and younger

18-29 years

30-39 years

40-49 years

50-59 years

60+

Prefer not to answer

What is your race/ethnicity? Please select all that apply. *

American Indian/ Alaskan Native (e.g. Aboriginal Australian, First Nations, Native American)

Asian (e.g. Central Asian, East Asian, South Asian, Southeast Asian)

Black/African American (having origins in Sub-Saharan Africa)

Middle Eastern/North African (including the Middle East, North Africa and the Arab World)

Native Hawaiian or Other Pacific Islander (a person having origins in any of the original people of Hawaii, Guam, Somoa, or other Pacific Islands)

White/European descent

Prefer not to answer

Required

Do you have any children? If so, how many? *

If you have indicated above that you have children, please provide their ages.

Are you currently pregnant? *

Yes

Please select which best applies to you. *

I am a single parent.

I am co-parenting.

I am a doula.

I am a midwife.

I am a caregiver.

I am a guardian.

Required

Would you like to stay connected with SGV AAIMM Community Action Team via email? *

Yes

Already on mailing list

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms