Join Our Wellness Network

Welcome! This form helps us connect you to health and wellness resources through Maven Community Health and our programs like The ManKave™

Please take 2 minutes to complete.

Contact Information

Full Name

Phone Number

Zip Code

Demographic & Identity (for equity & segmentation)

Gender Identity

Male Femail Non-Binary Prefer not to say

Ethnicity (Select all that apply)

Do you have children?

Yes No Prefer not to say

Are you affiliated with a faith-based organization?

Yes No Prefer not to say

Health Access & Navigation Needs

Do you currently have a primary care provider (PCP)?

Yes No Not sure

Do you currently have health insurance?

Yes No Not sure

Have you had any of the following screenings in the past 12 months?

Would you like help with any of the following? (Select all that apply)

Community Engagement & Segmentation

Are you currently registered to vote?

Yes No I'm not sure

How did you hear about us?

What would you like to receive from us?

Which of these describe you best? (For internal use – select all that apply)

May we contact you by

Email Text Message Phone Call Do not contact me

Consent & Final Steps

I consent to receive health-related info from Maven Community Health and understand my data will be stored securely and not shared or sold.

Digital Signature