JAMCHA Foundation, Inc - Spring Into Healthy Living 

Welcome to the Spring Into Healthy Living Appointment Request Form!
We are honored to serve our community.

JAMCHA Foundation, Inc. is a 501(c)(3) nonprofit organization dedicated to advancing health equity and promoting wellness across Eastern North Carolina. We are excited to offer Spring Into Healthy Living — a day of FREE preventive and primary care for adult residents of Nash and Edgecombe Counties.

Please complete this form to register and request an appointment. 
We will contact you to confirm your scheduled time if capacity allows. 

Learn more and support our mission:

Website: www.jamcha.org
Email: connect@jamcha.org

We are grateful to be part of this community — and we look forward to caring for you.

Let's "Spring Into Healthy Living" together as a community!

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First and Last Name *
Date of Birth *
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Gender *
Email *
Phone Number *
Mailing Address *
What county do you reside in? *
What is your annual household income?  (This will not affect your eligibility) *
How did you hear about the Spring Into Healthy Living event? *
Do you currently have health insurance? (For general purposes only) *
Do you have a (PCP) Primary Care Provider?  *
When is the last time you visited your (PCP) Primary Care Provider? *
When did you last have your labs/ bloodwork completed? *
Consent to Receive Care

I voluntarily request and consent to receive medical care and wellness services provided by Dr. LaToya McCurdy, FNP-BC medical provider at NEWH Regional Medical Center and the JAMCHA Foundation, Inc.. I understand that services may include a physical exam, wellness assessment, medication refill review (excluding controlled substances), and recommendations for ongoing health needs.

Initial below:

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One-Time Visit Agreement (No Ongoing Provider–Patient Relationship)

I understand that this is a one-time visit and does not establish Dr. McCurdy, FNP-BC or any JAMCHA Foundation provider as my primary care provider (PCP), nor does it create an ongoing provider–patient relationship. I am responsible for arranging all future medical care with my chosen healthcare provider.

Initial below:

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Liability Release & Indemnification

By receiving services, I agree that JAMCHA Foundation, Inc., Dr. McCurdy, all board members, volunteers, and clinical staff are not liable for any injury, loss, or damages arising from the care provided during this visit, and I waive any right to bring legal claims related to the services, medical advice, or treatment I receive.

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Appointment Request Disclaimer  
(Please read before submitting)

I understand that completing this form is a request for an appointment. Appointments will be scheduled in the order completed forms are received until capacity is reached. JAMCHA Foundation, Inc. will contact me by phone to confirm my appointment and share the location.  
I understand if I do not receive a confirmation call, I am not scheduled and will not receive care at the March 21, 2026 event.  

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Accuracy of Information

I certify that the information I provide is truthful and complete to the best of my knowledge.

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Type First and Last Name to serve as your official signature below:  *
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