Program Consent Form Consent Form Name * Required First Last Birthday * RequiredAddress * Required Street Address City State / Province / Region ZIP / Postal Code PhoneEmail Best way to contact you: * RequiredPhoneEmailWhat is Healthy Start? Healthy Start is a program for pregnant women, their infants and families in your community. The program’s purpose is to assist participants in many ways to help them live healthy lives. Healthy Start provides case management, referrals, education to its participants in a participant centered model that is designed to provide comprehensive, responsive, quality services to the participants/families enrolled in this initiative. What does the consent cover? By signing this consent form, I am consenting to participate in the UIC OCEAN-HP Healthy Families = Healthy Communities Healthy Start Program. By signing this consent I am also consenting for my Child/ren to participant in the UIC Healthy Families = Healthy Communities Healthy Start program.Name of child/renPlease separate names with a comma.Participant Agreement I am making this consent within the limits of my legal authority. I understand that I may revoke this consent at any time orally or in writing, but revoking this consent will not cancel what was done on my behalf before I revoked it. I also understand and agree to not hold UIC OCEAN-HP HFHC Program, liable, for the release of any information in accordance with the terms stated above in this consent.Consent * Required Clicking this checkbox is my consent to enroll in this program.NameThis field is for validation purposes and should be left unchanged.