Pre-Register / NWMSU Screening Event

Anthony Bates Foundation

Pre-Register / NWMSU Screening Event

Cardiac Screening Events Pre-Registration

This is to Register your

/ Student* /

/ Child* /

/ Athlete* or /

/ Young Adult* /

for the Sunday, November 21, 2010

FREE Heart Screening Event at NWMSU (location to be determined).

The Anthony Bates Foundation offers

FREE Heart Screening Tests,

although there are many costs involved.

Please help us continue our mission!

Make a donation today!

PreRegister Your Student/Athlete* Today!!

* suggested age of participants between 12 - 24

Student's Last Name
Student's First Name
Parents Last Name
Parents First Name
Gender	Male
Gender	Female
Preferred Time
Attending which school
Email Address
Phone Number
Address
Comments or Questions

Donate for your Cardiac Screening

Use your Credit Card

Student Discount

$ 20.00 suggested donation

Special:

Firefighters &

Gov't Workers

$ 65.00 suggested donation

Suggested Full Amount

$ 75.00 suggested donation