Location & Date

North Chicago High School
1717 Seventeenth Street
North Chicago, IL
map »
Wed. February 15, 2017
8:25 am - 3:05 pm

Contact & Other Information

Mary Beth Schewitz
Max Schewitz Foundation

e-Mail Event Organizer

Price: Free for all students

  Max Schewitz Foundation Screens for Teens at North Chicago HS - Feb. 15, 2017  
Hosted By: Phoenix Rising Foundation & Max Schewitz Foundation

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


The cardiac screening is being underwritten by Shields Township and the Max Schewitz Foundation.

Register by March 19, 2017 and receive a FREE copy of EKG by email.
     FREE Cardiac Screening & FREE copy of EKG ----
 Cardiac screening includes EKG and, if selected by cardiologist, an echocardiogram.

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

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:  *
Zip/Postal Code:  *
Mobile/Primary Phone #:   * (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

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 (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? 
(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? 
(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.


(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 $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.
In an effort to reduce SPAM, please enter below the code from the image above:

 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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