Lauderhill Healthy You Enrollment Form

Join us at a tour stop in your neighborhood! Explore health resources, connect with your community, and take steps toward a healthier life.

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Cell Phone Number

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* 5. Zip Code

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* 6. In Which Zone Do You Live/Do Business (if known)

Zone 1 - Northwest Lauderhill

Zone 2 - Inverrary/ Cypress Hollow / Forest Lakes

Zone 3 - Inverrary Association

Zone 4 - Central Lauderhill

Stop 5 - Deep Side / Devonhunt / Inverness Village

Zone 6 - Eastside

Zone 7 - West Kenlark / Lauderhill Point

Zone 8 - St. George / Broward Estate

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* 7. Which Tour Stop Will You Attend?

Environ Cultural Center - March 19th from 6pm to 8pm

Sadkins Center - April 23rd from 6pm to 8pm

Veteran's Park - May 20th from 6pm to 8pm

West Ken Lark Park - June 25th from 6pm to 8pm

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* 8. How Did You Hear About This Event?

Flyer

Social Media

Word of Mouth

Other (please specify)

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* 9. Gender

Male

Female

Non-binary/Other (Please specify)

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* 10. Age

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 11. Ethnicity

Black or African American

White/Caucasian

Hispanic or Latino

Haitian

Jamaican

Other (please specify)

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* 12. Primary Language

English

Spanish

Creole

Other (please specify)

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* 13. Relationship to Lauderhill

Resident

Business Owner

Student

Work in Lauderhill

Visitor

Other (please specify)

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* 14. Do You Require Any Special Accommodations?

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* 15. What Do You Hope to Gain From This Event?

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* 16. Please check the box below to opt-in to receive important updates and reminders about the Healthy You Tour and future health and wellness events

Yes, I would like to receive emails and texts

Lauderhill Healthy You Enrollment Form

Question Title

* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Cell Phone Number

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* 5. Zip Code

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* 6. In Which Zone Do You Live/Do Business (if known)

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* 7. Which Tour Stop Will You Attend?

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* 8. How Did You Hear About This Event?

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* 9. Gender

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* 10. Age

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* 11. Ethnicity

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* 12. Primary Language

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* 13. Relationship to Lauderhill

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* 14. Do You Require Any Special Accommodations?

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* 15. What Do You Hope to Gain From This Event?

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* 16. Please check the box below to opt-in to receive important updates and reminders about the Healthy You Tour and future health and wellness events

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* 17. Questions or Comments