Taking STEPS Together 2022
Please complete the TAKING S.T.E.P.S. registration form.
Participant Name
Participant Name
*
First
Last
Address
*
City
*
State
*
Zip code
*
Email
*
Cell
Cell
*
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Have you attended Taking Steps before?
*
Have you attended Taking Steps before?
Yes
No
Have you had a Mammogram in the past year?
*
Have you had a Mammogram in the past year?
Yes
No
Is your Mammogram covered by insurance?
Is your Mammogram covered by insurance?
Yes
No
Have you ever had a kidney screening for CKD (Chronic Kidney Disease)
*
Have you ever had a kidney screening for CKD (Chronic Kidney Disease)
Yes
No
Taking Steps Together Saves Lives!