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Period Party Registration Form
Free event! Food, desserts and period education! ISSA PARTY!
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* Indicates required question
Child's Name
*
Your answer
Grade
*
5th
6th
7th
8th
9th
Required
Does the youth have health insurance?
*
Yes
No
Is the health insurance provider Humana?
*
Yes
No
For youth: Are you currently experiencing menstrual cycles?
*
No
For youth: On a scale from 1 to 5, how confident do you feel about your knowledge of menstrual health and hygiene?
*
Low
1
2
3
4
5
High
For youth: Have you ever received formal education or guidance on menstrual health and hygiene?
*
Yes
No
Partially
School
*
Your answer
Zip Code
*
Your answer
Parent/Guardian Name
*
Your answer
Parent/Guardian email
*
Your answer
Parent/Guardian number
*
Your answer
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