First name:
Last name:
Date of Birth: (month/day/year)
Phone: (include area code)
Email:
Please read the Participation Agreement
Please read the Privacy Notice
(Please check this box once you acknowledge the copies above)
I understand the above and I agree to participate in Healthy Start Fatherhood Services program services administered by City of Milwaukee Health Department staff. By signing this consent form, I agree to allow the information described to be collected and kept by the program. I understand that my participation is voluntary and at any time, I can let my home visitor or the supervisor know verbally or in writing that I no longer want to participate.
Date: (month/day/year)
Patient/client refuses to acknowledge receipt
Thank you for submitting the form to Milwaukee Healthy Start.