HELPS Clinic Application for admission
Welcome to becoming a member of the HELPS Clinic and Resource Center. Please fill out the application below and someone will reach out to you within 2 weeks of application submission.
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Name *
First and last name
Date of birth *
What is your residential address?
Email *
Phone number *
Do you have medical insurance *
How many people live in your household? *
Are you employed? *
What is your annual salary?
Print name to indicate that all information is accurate. *
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