"Say It With Your Chest" Registration Form:
11AM on Saturday, February 1st 2025

Center for Black Women’s Wellness
477 Windsor St. SW Atlanta, GA 30312 Room 207
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Email *
Name *
What is the best phone number to reach you? *
Please provide your mailing address with zip code (We won't be mailing you anything. This information is for grant reporting purposes only). *
What is your gender? *
What ONE race do you identify with most? *
Required
What is your ethnicity?
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Have you been a CBWW client, patient, or participant before? Please select all that apply. *
Required
What age group do you belong to? 
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If you do NOT have insurance, are you interested in receiving low-cost clinic services at CBWW? 
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How did you hear about this event? *
Required
Do you or anyone you know have cervical cancer? *
Our panelist will include nurses, survivors, and medical professionals.  Do you have any questions for our panelist? *
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