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

Parent Information

Are you pregnant?
Can we text you?
Ok to leave message?
Do you have any children under the age of 5?

Child Information

List all children under the age of five.
I agree to the statement below
  • 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