Intake form

Name *

Email address *

What is your relationship to the student?

What age group does the student belong to?

Please select at least one option.

Elementary (K-5)

Middle School (6-8)

What topics are you interested in for health literacy?

Please select at least one option.

Nutrition

Physical Health

Mental Health

First Aid

Personal Hygiene

Healthy Relationships

Would you like to participate in interactive sessions?

Are you interested in learning about specific healthcare fields?

Please select at least one option.

Medicine

Nursing

Pharmacy

Physical Therapy

Occupational Therapy

Public Health

Do you have any suggestions for community engagement activities?

Which service or services are you interested in?

Please select at least one option.

Health literacy workshops

First aid kit donations

Healthcare career exposure

Additional questions or comments

Care4Connect