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HELPS Clinic Application for admission
Welcome to becoming a member of the HELPS Clinic and Resource Center. Please fill out the application below and someone will reach out to you within 2 weeks of application submission.
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* Indicates required question
Name
*
First and last name
Your answer
Date of birth
*
MM
/
DD
/
YYYY
What is your residential address?
Your answer
Email
*
Your answer
Phone number
*
Your answer
Do you have medical insurance
*
Yes
No
Required
How many people live in your household?
*
Choose
1
2
3
4
5
Option 6
Option 7
Are you employed?
*
Choose
Yes
No
What is your annual salary?
Your answer
Print name to indicate that all information is accurate.
*
Your answer
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