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Healthy Families Registration Form P RO G R A M TO S U P P O RT n e W PA R e n T S Please enter me in the program with the understanding that I may withdraw participation at any time. PARenTS’ nAMeS (please print) ________________________________________________________________________ ADDReSS ______________________________________________________________________________________ registration form CITy _________________________________________________ PHOne __________________________ STATe ___________ ZIP ________________ eMAIl _____________________________________________________ By providing my email address, I agree to receive emails from Healthy Families Howard County. Are you delivering at Howard County General Hospital? yes no Please confirm that you meet the following requirements: I am a Howard County resident: yes no My partner and/or myself are first-time parents: yes no How did you hear about the program? __________________________________ _______________________________________________________________ DUe DATe _______________________________________________________ DelIveRy DATe ____________________________________________________ SIGnATURe ________________________________________________________ For more details about this free program, call 410-715-3716. To participate, complete and mail this form to: Healthy Families Howard County, Family and Children's Services, 10451 Twin Rivers Road, Columbia, MD 21044. Healthy Families Howard County is part of the Healthy Families America initiative in the U.S. This free, national program identifies first-time parents in the community, aligns them with community resources and offers them support in their new role as parents. Optimally, families are welcomed prenatally into the program and are qualified to enroll up to 90 days after the birth of their baby. Healthy Families Howard County is a program of Howard County General Hospital and Family and Children’s Services.