Happy Mama Disaster Relief Program Question Title Reach is offering the Happy Mama platform at no cost through December 31, 2021, for those expectant and new mothers and maternal care teams affected by Hurricane Ida in Louisiana, New Jersey, and New York, the wildfires in Nevada and California, and other FEMA qualifying disaster areas. Qualifying individuals and care providers will receive six (6) months of access. Complete the form below and we will contact you to verify your information and process your enrollment. To Learn More about Happy Mama Visit the Happy Mama Website (http://happymama.global) Question Title * 1. Provide your contact information Name * Company Address * Address 2 * City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Country Email Address * Phone Number * Question Title * 2. Please indicate your enrollment type. Individual or Family Maternal Care Provider Question Title * 3. Provide a copy of your FEMA Qualification Letter PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Provide a copy of your FEMA Qualification Letter Question Title * 4. Reach will only be using this information for purposes of qualifying you or your institution for the Happy Mama Disaster Relief Program. Please read the Reach Policy Statement: https://reachtl.org/privacy-page Yes I understand and agree to the sharing of my information for purpose of enrollment in to the Happy Mama Disaster Relief Program No I do not agree. Done
