Enroll in Healthy Futures

We want to help you give your child a healthy future – and we do that by connecting you to trustworthy information and local resources.

Give your baby a healthy future.

Enroll Form

Notes

Parent Information

Name

First

Last

Parent's Birth Date

Are you pregnant?

Yes

Due Date (if unknown please provide an estimate)

Planned Delivery Hospital Planned Delivery Hospital

Address

City

State

Zip

County

Home Phone

Cell Phone

Alternate Phone

Can we text you?

Yes

Ok to leave message?

Yes

Name of delivery doctor or midwife

Do you have any children under the age of 5?

Yes

Child Information

List all children under the age of five.

Child's Full Name

Date of Birth

Child's Healthcare Provider

Birth Hospital

Add Remove

I agree to the statement below

I agree

By enrolling in Healthy Futures, I authorize the transfer of pertinent information about me and/or my children to healthcare providers and agencies participating in the program, on a need to know basis.
I understand and agree that the information transfer can occur by photocopy, electronic file transfer, and/or fax, as the program considers appropriate under the circumstances.
I also understand that the program includes data collection for the purpose of population studies and quality control and in no way will I or my children be identified personally in data reporting.
I understand that this authorization can be revoked in writing any time after it is signed and my participation in Healthy Futures can be terminated by notifying any member of the Healthy Futures team.
I also understand that this authorization will automatically expire at the end of participation in the Healthy Futures program.
I understand that I may refuse to sign this authorization and that my health care cannot be conditioned upon signing this authorization

If you are human, leave this field blank.

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This website was developed with support from the Community Foundation, a Michigan Health Endowment Fund grantee.

Healthy Futures serves 31 counties across northern Lower Michigan.

Alcona, Alpena, Antrim, Arenac, Benzie, Charlevoix, Cheboygan, Clare, Crawford, Emmet, Gladwin, Grand Traverse, Iosco, Isabella, Kalkaska, Lake, Leelanau, Manistee, Mason, Mecosta, Missaukee, Montmorency, Newaygo, Oceana, Ogemaw, Osceola, Oscoda, Otsego, Presque Isle, Roscommon, and Wexford Counties.