Location & Date

John Hersey High School
1900 E. Thomas Street
Arlington Heights, IL 60004
847-718-4800

map »
Wed. November 15, 2017
7:30am-3:15pm

Contact & Other Information

Mary Beth Schewitz
Max Schewitz Foundation

e-Mail Event Organizer

Price: $15.00




  Screens for Teens at JHHS/Forest View - 11/15/2017  
Hosted By: John Hersey High School

****REGISTER BY Nov. 5 & RECEIVE A FREE COPY OF YOUR EKG ****


 Registration
 

  • Cardiac screening includes EKG and, if selected by cardiologist, an echocardiogram.
  • Results will be sent within three weeks of testing.
     Cardiac Screening ---------------------------- @ $15.00
$0.00
 Register by 11/5/17: automatically receive a FREE copy of EKG by mail within three weeks of testing.

Has your student been approved as a FREE & REDUCED LUNCH student at John Hersey High School?
     Yes, approved as a FREE & REDUCED LUNCH student

 Donation:
Your support of our cardiac testing makes a life and death difference to area youth and your donation stays local.  
$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
 
75-100 Parent Volunteers Are Needed
Interested in volunteering at this screening? No experience necessary, training provided! 
 
STUDENT INFORMATION
One Student Per Registration 
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 
 
I grant permission for my child to be photographed:  
 
This permits my child to be photographed and/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
 
1. Does the student have any previously diagnosed heart disease? 
 
Includes: Anonmalous Coronary Artery, Aortic Aneurysm, Arrhythmogenic Right Ventricular Dysplasia Cardiomyopathy (ARVD/C), Brugada Syndrome, Chagas Disease, Congenital Heart Disease, Coronary Artery Disease (CAD), Dilated Cardiomypathy, Hypertrophic Cardiomyopathy (HCM), Long QT Syndrome, Marfan Syndrome, Non-Compaction Cardiomyopathy, Rheumatic Heart Disease, Valvular Heart Disease, Wolff-Parkinson-White Syndrome (WPW)

2. Does the student have any ongoing medical illnesses? 
 
3. Does the student take any medications other than birth control? 
 
HEART HEALTH QUESTIONS ABOUT PARENTS & SIBLINGS
(Consult a knowledgeable family member) 
Are you able to answer family health history questions? 
 
1. Has the student's parent or sibling died suddenly from a heart problem before the age of 50? 
 
2. Has the student's parent or sibling died suddenly for an unknown reason before the age of 50? 
 
Includes death for any reason including sudden infant death syndrome (SIDS), unexplained car accident, or drowning.

3. Does the student's parent or sibling have a genetic heart condition? 
 
Includes: Hypertrophic Cardiomyopathy, Dilated Cardiomyopathy, Long QT Syndrome, Marfan Syndrome or other Heart Rhythm problems.

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 tested, a refund will be issued within two weeks. If you would like to donate your child's registration so other students can be tested, please email: Kathy@maxschewitzfoundation.org

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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