Health + Healing Hubs Participant Registration

"*" indicates required fields

Participant Name / Nombre del participante*

First Last

Email / Correo electrónico*

Enter Email Confirm Email

Email / Correo electrónico*

Enter Email Confirm Email

Date of Birth / fecha de nacimiento*

MM slash DD slash YYYY

Is the participant under 18 years old/ ¿El participante es menor de 18 años?*

Yes

Zip Code / Código postal:*

Street Address City State ZIP Code

Phone number / Número de teléfono:*

Gender / género*

Female / Mujer

Male / Masculino

Nonbinary/no binario

Transgender/Transgénero

Prefer not to describe / Prefieren no responder

Other / Otro

What race do you identify with? / ¿Con qué raza te identificas?*

Choose all that apply / (Elija todas las que correspondan)

American Indian/Alaskan Native / Indio americano/nativo de Alaska

Asian / asiático

Black/African American / Negro/ afroamericano

Native Hawaiian/Pacific Islander / Nativo de Hawái / Isleño del Pacífico

White Caucasian / Caucásico blanco

Prefer not to respond / Prefiero no contestar

Prefer to self-describe

Prefer to self-describe / Prefiere autodescribirse:

Do you identify as Latino/a/e/x? / ¿Te identificas como latino / a / e / x?*

Yes / Sí

No / No

Please select any of the following services you're currently receiving:*

Medicaid

CHIP

Sliding Fee Scale /Escala móvil de tarifas

WIC

Medicare

MAP / MAPA

SNAP

None of the above / Ninguna de las anteriores

Estimated Annual Household Income*

Number of individuals living in the household*

How did you hear about us? / ¿Cómo se enteró de nosotros?*

Word of Mouth / Boca a boca

Social Media / Medios de comunicación social

Event Website / Sitio web del evento

Internet Search / Búsqueda de internet

Email Newsletter / Boletín electrónico

Printed Materials (flyers, newspaper, etc.) / Materiales impresos (volantes, periódicos, etc.)

Non-Profit agency / Agencia sin fines de lucro

Healthier Texas Community Challenge / Desafío comunitario de Healthier Texas

Higher Praise Family Church

Rising Start Church

Other / Otro

Other / Otro*

What is your preferred language? / ¿Cuál es tu idioma preferido?*

English / Inglés

Spanish / Español

Other

Would you like to subscribe to the Healthier Texas email newsletter? / ¿Le gustaría suscribirse al boletín electrónico Healthier Texas?*

Yes / Sí

No / No

Wellness Questions / Preguntas de Bienestar

Do you have a current diagnosis of any of the following?*

(Check all that apply)

Diabetes

High blood pressure

High cholesterol

Asthma/COPD

Heart disease

None

If you do have a current diagnosis, do you currently take any prescribed medications to manage it?*

Yes

How would you rate your current physical health?*

Excellent

Good

Fair

Poor

Do you have any physical or mental limitations that affect your daily living?*

Yes

What is your current housing situation?*

Stable

Temporary

At risk of losing housing

Homeless

Do you have access to transportation to get to medical appointments, work, or school?*

Yes

How often do you eat fruits and vegetables each day?*

(One serving is about 1 small apple or 12 baby carrots)

Stable

Temporary

At risk of losing housing

Homeless

Do you have reliable access to enough food each day?*

Yes

What is the highest level of education completed?*

Less than high school

High school / GED

Some college

College degree or higher

Are you currently employed?*

Yes, full-time

Yes, part-time

Do you have health insurance?*

Yes

Do you currently have a primary care provider or clinic you go to regularly?*

Yes

Do you feel safe in your home and neighborhood?*

Yes

Do you have someone you can count on for emotional support?*

Yes

In general, how would you rate your mental/emotional health?*

Excellent

Good

Fair

Poor

In the past 2 weeks, how often have you felt stressed or overwhelmed?*

Rarely

Sometimes

Often

Always

How satisfied are you with your current level of physical activity?*

Very satisfied

Somewhat satisfied

Not satisfied

Do you feel you have control over your health and wellness decisions?*

Rarely

Sometimes

Often

Always

How confident are you in your ability to manage your health conditions and goals?*

Very confident

Somewhat confident

Not confident

How comfortable do you feel talking about health with your family and friends?*

Very confident

Somewhat confident

Not confident

How well are you able to meet your daily responsibilities (work, family, self-care)?*

Very well

Fairly well

Not well

What is one health related goal you would like support with?*

What types of additional support would be helpful to you right now?*

(Check all that apply)

Housing assistance

Food or nutrition support

Mental health counseling

Help with employment or job training

Help applying for benefits (e.g., SNAP, Medicaid)

Help finding a doctor or medical home

Physical activity programs

Parenting or childcare support

Transportation assistance

Other

If other, please specify:*

Health Screening/ Chequeo de Salud:

A Community Health Educator will help record your blood pressure/Una Educador de Salud Comunitaria le ayudara a revisary anotar su presión arterial

Blood Pressure/ Presión Arterial*

Height /Altura*

Weight/Peso*

Health + Healing Hub Participant Consent

Consent*

I CONSENT TO RECEIVE SERVICES FROM THE HEALTH + HEALING HUBS PROGRAM. I UNDERSTAND MY INFORMATION WILL BE KEPT CONFIDENTIAL AND ONLY SHARED WITH MY PERMISSION OR AS REQUIRED BY LAW.

Date*

MM slash DD slash YYYY

LIABILITY WAIVER/EXENCIÓN DE RESPONSABILIDAD*

I have read and agree to this program’s terms and conditions. / He leído y acepto los términos y condiciones de este programa.

IN CONSIDERATION OF PARTICIPANT BEING ALLOWED TO PARTICIPATE IN THE REGISTERED CLASS(ES) OR PROGRAM(S), THE UNDERSIGNED HEREBY RELEASES THE HEALTHIER TEXAS, ITS EMPLOYEES AND AGENTS, FROM ANY ACTION, CLAIM OR DEMAND FOR PERSONAL INJURY OR PROPERTY LOSS ARISING FROM OR DUE TO ANY NEGLIGENT ACT OR OMISSION OF HEALTHIER TEXAS, ITS AGENTS OR EMPLOYEES. THIS RELEASE SHALL HAVE NO EFFECT WITH REGARD TO DAMAGES CAUSED BY HEALTHIER TEXAS’ GROSS NEGLIGENCE. IN THE EVENT IT’S TIME TEXAS OR A VOLUNTEER PROVIDES TRANSPORTATION FOR THE REGISTERED PARTICIPANT, THIS WAIVER AND RELEASE SHALL EXTEND TO AND RELEASE HEALTHIER TEXAS EMPLOYEE DRIVER FROM ANY AND ALL LIABILITY. PERMISSION IS GIVEN FOR ANY EMERGENCY MEDICAL TREATMENT, OPERATION OR ANESTHESIA WHICH MIGHT BECOME NECESSARY. I AGREE TO BE RESPONSIBLE FOR THE EXPENSE OF MEDICAL TREATMENT OR SERVICE.

EN CONSIDERACIÓN DE QUE SE PERMITA A LOS PARTICIPANTES PARTICIPAR EN LAS CLASES O PROGRAMAS REGISTRADOS, EL ABAJO FIRMANTE LIBERA HEALTHIER TEXAS, SUS EMPLEADOS Y AGENTES, DE CUALQUIER ACCIÓN, RECLAMO O DEMANDA POR LESIONES PERSONALES O PÉRDIDA DE PROPIEDAD QUE SURJA DE O DEBIDO A CUALQUIER ACTO NEGLIGENTE U OMISIÓN DE HEALTHIER TEXAS, SUS AGENTES O EMPLEADOS. ESTE LANZAMIENTO NO TENDRÁ NINGÚN EFECTO CON RESPECTO A LOS DAÑOS CAUSADOS POR LA NEGLIGENCIA GRAVE DE HEALTHIER TEXAS. EN CASO DE QUE HEALTHIER TEXAS O UN VOLUNTARIO BRINDE TRANSPORTE PARA EL PARTICIPANTE REGISTRADO, ESTA EXENCIÓN Y EXENCIÓN SE EXTENDERÁ Y LIBERARÁ AL CONDUCTOR DEL EMPLEADO DE HEALTHIER TEXAS DE TODA RESPONSABILIDAD. SE OTORGA PERMISO PARA CUALQUIER TRATAMIENTO MÉDICO DE EMERGENCIA, OPERACIÓN O ANESTESIA QUE PUEDA SER NECESARIA. ACEPTO SER RESPONSABLE DEL GASTO DEL TRATAMIENTO O SERVICIO MÉDICO.

Media Release Clause / Cláusula de Autorización de Uso de Imagen y Medios*

HEALTHIER TEXAS IS 501 (C) (3) A NON-PROFIT ORGANIZATION THAT PROVIDES TEXANS WITH CREATIVE AND PROGRESSIVE HEALTH-AND FITNESS-ORIENTED PROGRAMMING, INFORMATION AND EVENTS. BY SIGNING BELOW, YOU AGREE TO GIVE THE HEALTHIER TEXAS ORGANIZATION PERMISSION TO USE YOUR IMAGE, VOICE, AND QUOTATIONS, FREE OF CHARGE, IN ALL OF OUR PROMOTIONAL MATERIALS, INCLUDING, BUT NOT LIMITED TO OUR BROCHURES, ADS, SOCIAL MEDIA, AND WEBSITE. WE MAY USE YOUR FIRST NAME ONLY, UNLESS OTHERWISE REQUESTED TO PROMOTE YOUR HEALTH-RELATED WORK. IF YOU OBJECT TO ANY OF THESE USES, PLEASE INDICATE BELOW WHICH ITEMS WE ARE NOT TO DISCLOSE. VISIT OUR WEBSITE OFTEN FOR UPDATES AND INFORMATION AT: WWW.HEALTHIERTEXAS.ORG

HEALTHIER TEXAS ES UNA ORGANIZACIÓN 501 (C) (3) SIN FINES DE LUCRO QUE OFRECE A LOS HABITANTES DE TEXAS INFORMACIÓN, ACTIVIDADES CREATIVAS Y PROGRAMAS PROGRESIVOS ORIENTADOS A LA SALUD Y EL BIENESTAR FÍSICO. AL FIRMAR ESTE DOCUMENTO, USTED AUTORIZA A LA ORGANIZACIÓN HEALTHIER TEXAS A UTILIZAR SU IMAGEN, VOZ Y CITAS, DE FORMA GRATUITA, EN TODOS NUESTROS MATERIALES PROMOCIONALES, INCLUIDOS, ENTRE OTROS, NUESTROS FOLLETOS, ANUNCIOS, CONTENIDOS EN REDES SOCIALES Y SITIO WEB. SOLO PODREMOS UTILIZAR SU NOMBRE DE PILA, A MENOS QUE SOLICITE LO CONTRARIO CON EL FIN DE PROMOCIONAR SU TRABAJO EN EL ÁMBITO DE LA SALUD. SI NO ESTÁ DE ACUERDO CON ALGUNO DE ESTOS USOS, POR FAVOR INDIQUE A CONTINUACIÓN QUÉ ELEMENTOS NO PODEMOS DIVULGAR. VISITE NUESTRO SITIO WEB CON FRECUENCIA PARA OBTENER ACTUALIZACIONES E INFORMACIÓN EN: WWW.HEALTHIERTEXAS.ORG

Yes / Sí, doy mi consentimiento

No / No, no doy mi consentimiento

Consent Objections / Objeciones de Consentimiento*

Please list which items Healthier Texas is not to disclose / Por favor, indique cuáles elementos Healthier Texas no debe divulgar.

Under 18 Participant Consent / Consentimiento para participantes menores de 18 años

I, the parent/legal guardian of the participant, hereby agree to all the above on behalf of the participant. / Yo, padre/tutor legal del participante por el presente acepto todo lo anteriormente mencionado en nombre del participante

FOR EMERGENCY USE / PARA USO DE EMERGENCIA

Emergency Contact Information / Información del Contacto de Emergencia

Participant Name/ Nombre del participante*

First Last

Emergency Contact Name / Contacto de Emergencia Nombre*

First Last

Phone number / Número de teléfono:*

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Health + Healing Hubs Participant Registration

Wellness Questions / Preguntas de Bienestar

Health Screening/ Chequeo de Salud:

Health + Healing Hub Participant Consent

FOR EMERGENCY USE / PARA USO DE EMERGENCIA

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