Registration Form

I am consenting to be entered into the Mama Thrive Program, a part of the Severe Maternal Morbidity Telehealth Program (SMMT).

I authorize Agape Family Health and other Community Partner's to gather information, contact me by all available ways (Call, Email, Text, Mail, Telehealth, Notifications, etc.) and provide additional services during pregnancy and 3 months postpartum.

I understand that all information gathered may be used to determine program eligibility. This authorization remains in effect until revoked in writing by me.