Pre-Registration / DHPA, Glendale, AZ Cardiac Screening

Anthony Bates Foundation

Pre-Registration / DHPA, Glendale, AZ Cardiac Screening

This is to Register YOU

/or /

/ your family member /

for our Arizona Cardiac Screening Day

Saturday, April 28, 2012

Heart Screening Program at

Desert Heights Prep Academy

in Glendale, AZ.

The Anthony Bates Foundation offers

CARDIAC SCREENINGS for a tax deductible

donation. Tests include ECG, Echocardiogram,

blood pressure & cardiac questionnaire

for ages above 11 that are interested.

Please help us continue our mission!

Have your heart screened for peace of mind!

Make an appointment today!

PreRegister Today!!

++ Top Two (2) or more schools participating in April events will receive a donation of

an AED (automatic external defibrillator) of their choice.

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 Low Cost Screening

Use your Credit Card

Student Discount

$ 40.00 suggested donation

Special:

Firefighters &

Gov't Workers

$ 65.00 suggested donation

Suggested Full Amount

$ 75.00 suggested donation