Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

MAHF Tennessen Warning

  1. Metro Alliance for Healthy Families Logo

  2. THE METRO ALLIANCE FOR HEALTHY FAMILIES [MAHF]

    The Metro Alliance for Healthy Families (MAHF), is a partnership among the metropolitan counties of Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, and Washington, and the City of Bloomington (MAHF Members).

  3. TENNESSEN WARNING

    Your participationin the MAHF Program is strictly voluntary. If you choose to participate, a MAHF Parent Visitor will ask you for information about yourself and your child(ren) including your age, education level, marital status, public assistance status, health insurance status, race/ethnicity, the language you speak, and you child's birth weight, gestational age, special needs, race/ethnicity, health insurance status, and the language the child speaks. You will periodically be asked for updates to your information. This information will help ensure you receive appropriate services including MAHF home visiting. This information is classified as private data under the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13. Data related to you and the services you receive will be maintained in a computer database managed by Dakota County on behalf of the MAHF Members.

  4. You are not required to furnish any of the information requested. If you choose not to provide information, the MAHF Parent Visitor may not be able to determine if you would benefit from participating in the MAHF Program and may not be able to offer you MAHF services. If you decide not to participate in the MAHF Program, your decision will not affect services you may already be receiving from any MAHF Member.

    The information applies to your current and future contact with the MAHF Program, through any of the MAHF Members or MAHF Parent Visitor(s), whether the contact is in person, or by mail, email, fax, or telephone.

  5. Sharing Information

    Should you decide to participate, the information you provide to a MAHF Parent Visitor will only be shared with the MAHF Member of your county/city of residence (including any persons or entities that the MAHF Member is under contract with to provide MAHF Program Services) and the Minnesota Department of Health (MDH). If you move to another MAHF county/city while participating in the MAHF Program, your data will then be shared with the MAHF Member of the county/city to which you move (including any persons or entities that this MAHF Member is under contract with to provide said services). The MAHF Member will not release your private data to anyone else without your consent, unless otherwise authorized by law or court order. In addition, the private data about you and your children will be shared with the MAHF Fiscal and Administrative Agent (Dakota County is the Fiscal and Administrative Agent for the MAHF Program at this time.) for the limited purposes of creating summary data (information that does not include any data that could identify an individual) for funding, evaluation and research on the MAHF Program and to maintain the MAHF database.

  6. I wish to participate in the Metro Alliance for Healthy Families [MAHF] Program. As a participant, I understand and agree that private data about me and my child(ren) will be shared with the MAHF Member in my county of residence, the Minnesota Department of Health (MDH), and the MAHF Administrative and Fiscal Agent(s). This information will be maintained in a computer data system managed by Dakota County.

  7. I agree and consent to providing a digital signature.

  8. Leave This Blank:

  9. This field is not part of the form submission.