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The M.O.M.S. Tour Registration Form
Please register for the M.O.M.S. Tour by completing the form below. For those interested in on-site vaccines, please bring your ID and insurance card. Note: Some locations may require you to wear a mask.
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* Required
Email
*
Your email
First and Last Name
*
Your answer
Please select your age below:
*
18-24
25-34
35-44
45+
Required
Ethnicity
*
African American
Native American
Alaska Native
Hispanic
Caucasian
Other
Explain Other (If you selected other for Ethnicity)
Your answer
Gender
*
Female
Male
Non-binary
Other
Registration Type
Expecting mom (person)
Expecting mom (person)/Military (active or veteran)
A parent (mom, dad, grandparent)
Birthing Professional (doula, midwife, aspiring doula)
Healthcare Professional (doctor, nurse, social worker)
Community Organizations (nonprofit, preschool, church)
Clear selection
I'm Attending ...
*
St. Louis, MO - March 25th
Kansas City, MO- March 26th
Newark, NJ- April 15th
Brooklyn, NY- April 16th
Anchorage, AK- May 6th
Fairbanks, Ak- May 7th
Atlanta, GA- May 20th
Macon, GA- May 21st
Indianapolis, IN- June 10th
Ft. Wayne, IN- June 11th
Los Angeles, CA- June 24th
Fresno, CA- June 25th
Baton Rouge, LA- July 1st
New Orleans, LA- July 2nd
Greenwood, MS- July 15th
Jackson, MS- July 16th
Detroit, MI- August 12th
Flint, MI- August 13th
Dallas/Ft.Worth, TX- September 22nd
Houston, TX- September 23rd
Baltimore, MD- September 30th
Prince Georges County, MD- October 1st
Memphis, TN- October 7th
Little Rock, AR- October 8th
Oklahoma City, OK- October 21st
Tulsa, OK- October 22nd
San Juan, PR- November 11th
Do you need healthcare (prenatal)?
Yes
No
Are you interested in (Doula, Midwife, etc.) support during pregnancy?
Yes
No
Maybe
Do you need Medicaid coverage?
Yes
No
Maybe
Do you feel like your emotions are all over the place sometimes? Do you feel sad for long periods of time and need to speak to someone confidentially?
Yes
No
Maybe
Please keep me informed about upcoming events and information.
*
Yes
No
Required
A copy of your responses will be emailed to the address you provided.
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