Location & Date

Warren Township HS
Almond Campus
34090 Almond Road
Gurnee, Illinois 60031
map »
Wed. March 8, 2017
7:30 am - 3:15 pm

Contact & Other Information

Mary Beth Schewitz
Max Schewitz Foundation

e-Mail Event Organizer

Price: $15




  Screens for Teens at WTHS ALMOND CAMPUS March 8, 2017  
Hosted By: Warren Township HS ALMOND CAMPUS

****************** ONE STUDENT PER REGISTRATION **********


 Registration
 

Registrations on/after Feb.26, 2017:
     Cardiac Screening ---------------------- @ $15.00
$0.00
     Cardiac Screening & $10 copy of EKG ------ @ $25.00
$0.00

  My child qualifies for FREE & REDUCED LUNCH:
     Free & reduced lunch- EKG screening
     Free & reduced lunch- screening & copy of EKG @ $10.00
$0.00
 Registration on/after 2/27/17

 Donation:
I/We cannot participate, but would like to make a donation.
- or -
I/We would like to make an additional donation
 
$0.00

Total:  $0.00 Update
 

 Primary Contact Information
PRIVACY & SECURITY >>
Primary e-Mail Address:  * (used to send your confirmation)




First Name: *
Last Name:  *
Company Name:  (optional)
Address:  *
City:  *
State:    
Zip/Postal Code:  *
Country: 
Primary Phone #:   * (mobile phone number preferred. include intl. code)
   

* Required Fields

For your convenience, you may setup your Events.org Account. The account allows you to manage your registration and donation info and to fill it with one simple step, next time you are on Events.org.
 

 Additional Information

PARENT INFORMATION: ENTER IN PRIMARY SECTION ABOVE
 
75 Parent Volunteers Are Needed
Are you interested in volunteering at this screening? 
 
No experience necessary! Training and supervision provided by medical staff. Please use VOLUNTEER REGISTRATION LINK located at top left corner. (You are NOT registered to VOLUNTEER until link is used.)

Student First Name 

(limit your response to 200 characters)  
Student Last Name 

(limit your response to 200 characters)  
Student Gender 

 
Student Race 
 
Student Date of Birth 
(MM/DD/YY)    
Example: 04/19/99

Student ID Number 
   
Student Weight in Pounds 
   
Number only. Example: 133

Student Height (to nearest inch) 
 
I grant permission for my child to be photographed:  
 
This permits my child to be photographed, or appear in recording of this event for any legitimate purpose.

Does your student participate on a sports team at school or outside of school? 
 
HEALTH QUESTIONS ABOUT THE STUDENT
(Student should complete) 
Do you have any previously diagnosed heart disease? 












 
Do you have any ongoing medical illnesses? 
 
Are you taking any medications? 
 
Do you have unexplained shortness of breath or fatigue with exercise? 
 
Have you been told you have a heart murmur? 
 
Have you ever had an unexplained seizure? 
 
Does your heart ever suddenly race (beat fast) without good reason? 
 
Do you get chest pain when you exercise? 
 
Have you ever been restricted from participating in sports due to a heart condition? 
 
Have you ever passed out or nearly passed out? 
 
Have you had high blood pressure or high cholesterol? 
 
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
(Consult a knowledgeable family member) 
Has anyone in your family died suddenly FROM A HEART PROBLEM before the age of 50? 
 
Includes grandparents, parents, uncles, aunts, siblings, or cousins.

Has anyone in your family died suddenly for an unknown reason before the age of 50? 
 
Includes grandparents, parents, uncles, aunts, siblings, or cousins. Includes death for any reason including sudden infant death syndrome (SIDS), unexplained car accident, or drowning.

Does anyone in your family have a genetic heart condition? 
 
Includes grandparents, parents, uncles, aunts, siblings, or cousins.

Additional Comments
Regarding YES answers to medical questions above.
 
 


 Payment

*
 
*
 
*  
*
   
*
(usually the last 3-4 digits on the signature panel)  

/
(if different from address above)



I authorize Events.org on behalf of  Max Schewitz Foundation to charge my credit card/debit card (when selected above) $0.00.  If using a debit card, the amount will be automatically deducted from your checking account.
I also confirm that I am 18 or older.
 
 

 Waiver Agreement

 
 

Clicking the Process Now button will process your transaction, if all information is correct. Please wait for your confirmation receipt to display.
A confirmation will also be e-mailed to you.

  Please only click once.

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Purchase/refund policy: If you prepay and your student is not screened, please consider donating the registration fee to the Max Schewitz Foundation so other students may be tested or you may request a refund.

Events.org's Purchase/refund policy: Refunds and cancellations are provided only at the discretion of the organization hosting or sponsoring this event. Events.org issues credits only when directed to do so by the sponsoring organization. Contact the sponsoring organization for further details.

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