Location & Date

Glenbrook North High School
2300 Shermer Rd.
Northbrook, IL. 60062
map »
Wed. November 7, 2018

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



  • Cardiac screening includes EKG and, if selected by cardiologist, an echocardiogram.
  • Results will be sent within three weeks of testing.
     Cardiac Screening ---------------------------- @ $15.00
 Free copy of the EKG has expired.
     Cardiac Screening $15 & $10 copy of EKG -------- @ $25.00
 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

Your support of our cardiac testing makes a life and death difference to area youth and your donation stays local.  

Total:  $0.00 Update

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

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

* Required Fields

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 Additional Information

75 Parent Volunteers Are Needed
Interested in volunteering at this screening? No experience necessary, training provided! 
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 
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.

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? 
Additional Comments


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

(if different from address above)

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 Waiver Agreement


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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

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