Screens for Teens at Glenbrook North HS

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Location & Date

Glenbrook North High School
2300 Shermer Rd.
Northbrook, IL. 60062
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Wed. November 7, 2018
7:00am-2:45pm

Contact & Other Information

Mary Beth Schewitz
Max Schewitz Foundation

e-Mail Event Organizer

Price: $15.00


	Screens for Teens at Glenbrook North HS - 11/7/2018
	Hosted By: Glenbrook North High School

	**REGISTER BY 10/24/2018 & RECEIVE A FREE COPY OF YOUR STUDENT'S 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

Free copy of the EKG has expired.

Cardiac Screening $15 & $10 copy of EKG -------- @ $25.00

$0.00

Optional $10 copy of EKG will be sent within three weeks of testing.

Has your student been approved as a FREE & REDUCED LUNCH student at Glenbrook North High School? This information will be confirmed by GBN Administration. If not confirmed, payment will be due.

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 >>

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Additional Information

PARENT INFORMATION: ENTER IN PRIMARY SECTION ABOVE

75 Parent Volunteers Are Needed

Interested in volunteering at this screening? No experience necessary, training provided! *

YesNo

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 *

M
F

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: *

YesNo

This permits my child to be photographed and/or appear in recording of this event for any legitimate purpose.

HEALTH QUESTIONS ABOUT THE STUDENT

1. Does the student have any previously diagnosed heart disease? *

YesNo

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? *

YesNo

3. Does the student take any medications other than birth control? *

YesNo

Additional Comments

Payment

Pay by Credit Card/Debit Card

Name on Card:*
Card Type:*
Card Number:*
Expiration:*
Card Security Code: * (usually the last 3-4 digits on the signature panel)
Card Address: / (if different from address above)

My student will pay at the screening

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.

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Waiver Agreement

I understand that my child's participation in Screens for Teens Cardiac Screening is intended to identify heart abnormalities, which may affect her/his health during physical activity.  I assume all risks associated with my child's participation in the cardiac screening. As a result of the screening, I may be advised to seek follow-up testing or treatment for my child with a physician.  Physician encounters and future tests are not considered part of the screening and thus may incur cost.  All such risks being known and appreciated by me, and having read this waiver, I hereby for myself, child, heirs, executors, and administrators waive any and all claims of any kind or nature, I may have against the Max Schewitz Foundation, NorthShore University HealthSystems, Glenbrook North High School, and any and all individuals associated with this screening, and their heirs, representatives, and successors, and assigns for any and all injuries suffered by me or my children in connection with this screening.  I understand de-identified health information collected, including the EKG and echo results, may be used in cardiac research.  I understand that usual and accepted standards will be used to keep my child's health information confidential.  If registering after the early registration period, I understand I will not receive the actual EKG or echo but will receive an email from the Max Schewitz Foundation with my child's results and an opportunity to obtain a copy of the EKG for a $10 handling fee.

I agree to the above waiver

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A confirmation will also be e-mailed to you.

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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. Events.org provides Online Event Registration, Donations, Attendee Management and Event Publishing on behalf of the organization. If you experience difficulties using this site, please contact help@events.org or call us at (847)513-6460.

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