July 2025: Mental Health & Sickle Cell Awareness Registration Form
July 26, 2025
11:00am -12:30pm ET
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
*
3.
Email
(Required.)
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4.
Phone Number
(Required.)
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5.
Age
(Required.)
Under 18
18-24
25-34
35-44
45-54
55-64
65-74
75 years or older
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6.
Gender
(Required.)
Male
Female
Non-Binary
Prefer not to specify
Prefer to Self-Describe:
*
7.
Race/Ethnicity (please check all that apply)
(Required.)
Asian / Pacific Islander
Black or African American
Hispanic or Latinx
Native American or American Indigenous
White
Other Race
Prefer not to specify
Unknown/Undetermined
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8.
City and State of Residence
(Required.)
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9.
On a scale from 1 to 7, how knowledgeable are you about mental health awareness?
(Required.)
1-Not at all knowledgeable
2
3
4-Somewhat knowledgeable
5
6
7-Extremely knowledgeable
Not sure
1-Not at all knowledgeable
2
3
4-Somewhat knowledgeable
5
6
7-Extremely knowledgeable
Not sure
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10.
On a scale from 1 to 7, how knowledgeable are you about sickle cell disease?
(Required.)
1-Not at all knowledgeable
2
3
4-Somewhat knowledgeable
5
6
7-Extremely knowledgeable
Not sure
1-Not at all knowledgeable
2
3
4-Somewhat knowledgeable
5
6
7-Extremely knowledgeable
Not sure
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11.
Have you or someone in your immediate family been diagnosed with sickle cell disease? Please select all that apply.
(Required.)
Yes, just myself
Yes, someone in my immediate family
Yes, myself and someone in my immediate family
No
Unsure
Prefer not to specify
*
12.
If you have received a diagnosis, how would you rate the severity of your sickle cell disease?
(Required.)
1-Mild
2
3-Moderate
4
5-Severe
Not Sure
Not Applicable
1-Mild
2
3-Moderate
4
5-Severe
Not Sure
Not Applicable
13.
Are you interested in participating in this month's healthy challenge (a meditation and breathing challenge)?
Yes
No
