Event Registration

Join us for Women's Health Night!
Wednesday, April 13 5:30-7:30 pm
Clark Memorial Health Sellersburg
130 Hunter Station Way
Sellersburg, IN 47172

Thank you for registering for the Women's Health Night in Sellersburg.

Enter for a chance to win a gift card!

Please complete the form and indicate your acknowledgement to voluntary release and consent to health screening below.

Voluntary Release and Consent to Event Participation

I acknowledge that I have voluntarily chosen to participate in this health screening or event sponsored by Clark Memorial Health. In connection with my health fair participation, I hereby voluntarily agree to the following: Consent to Health Screening, General Release, Distributed Materials, Responsibility for Further Treatment, and Notice of Privacy Practices.

Name

Phone

E-mail

Address

City and State

Zip Code

I agree to Voluntary Release and Consent to Health ScreeningYes, I agree