SECURE REGISTRATION FORM: Complete this form to register for any classes or services. If you are preregistering, notify the reception desk you have already registered when you arrive. We have two classes during the day on Saturdays: 10am and 2pm.The classes are free and start promptly at 10am and 2pm, with space limited to 10 seats per class. Attendance is on a first-come, first-serve basis. Registration closes when the class starts (either 10a or 2p). Ten (10) minutes after the class begins, we will ask new arrivals to come back for the next class.
Email address *
Classroom for Naloxone Administration and Food Handlers Training
First 2 letters of first name *
Your answer
First 2 letters of mother's first name *
Your answer
Middle Initial or Middle Name (optional)
Your answer
2-digit year of birth
Your answer
Address (Can be work or home, etc.)
Your answer
CITY *
Your answer
STATE *
ZIP CODE
Your answer
Telephone Number with Area Code *
Your answer
Ethnicity (optional)
Tribal Affiliation
Sex at Birth
Gender
Is this your first time visiting Gallup Health Cooperative?
Which services are you preregistering for? (optional)
About what time do you plan on arriving?
Do you have a primary physician? (optional)
Where do you receive healthcare? (optional)
Are you experiencing any symptoms? (check the best answer)
How did you hear about us?
Express Visit (initial here if you want the "Express Screening")
If I have requested a sexual health screening, such a rapid HIV, Syphilis or HCV exam, I just want the express visit service. I do not need a counselor to speak with me about the details on how these infections are transmitted nor do I need the counselor to ask me questions about reducing my risk to certain infections, such as HIV and Syphilis. I realize if I leave this section without circling it, that the counselor may take the recommended time to ask me questions about reducing my risk to infection. (If you are not having a sexual health screen, please leave this area unmarked)

Would you like the "Express Screening" today? (optional)
Signature (type your name or initials) *
Your answer
Today's Date
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