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The Breaking Curses Health Initiative Registration Form
Just Schooling Registration Form | Address: West End Park Located at 1111 Oak St 30310
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* Indicates required question
Email
*
Your email
Individual Name or Company Name
*
Your answer
Phone Number
Your answer
Ethnic origin: Please specify your ethnicity.
*
White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian / Pacific Islander
Other:
Age: What is your age?
*
Under 12 years old
12-17 years old
18-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years or older
Education: What is the highest degree or level of school you have completed? If currently enrolled, highest degree received.
*
No schooling completed
Nursery school to 8th grade
Some high school, no diploma
High school graduate, diploma or the equivalent (for example: GED)
Some college credit, no degree
Trade/technical/vocational training
Associate degree
Bachelor’s degree
Master’s degree
Professional degree
Doctorate degree
Marital Status: What is your marital status?
*
Single, never married
Married or domestic partnership
Widowed
Divorced
Separated
How many children?
*
Choose
0
1
2
3
4
5
5 or more
Employment Status: Are you currently…?Employed
*
Employed for wages
Self-employed
Out of work and looking for work
Out of work but not currently looking for work
A homemaker
A student
Military
Retired
Unable to work
Do you feel Stressed?
*
Yes
No
How would you rate your stress from 1-10 one being the least 10 the highest ?
*
Choose
1
2
3
4
5
6
7
8
9
10
What do you do to help manage your stress?
*
Exercise,
Smoke: Ciagrette, tobacoo, Cannibas
Smoke: Cannibas
Drink
Increase sexual activity
Eat
Sleep
Spiritual connect
Isolate
Drugs
Party
Other:
Does having resources as one stop shop help relieve stress during the Breaking Curses Health Initiative?
*
Yes
No
What does stress do to your body?
*
Increase blood pressure
Cause generalized pain
Increases sleeplessness
Headaches
Migranes
Depression
Anxiety
Increase or decrease appetitie
Causes trembles, shakes,
A copy of your responses will be emailed to the address you provided.
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