KEEP Healthy Registration Form
PLEASE NOTE: IF YOU REGISTER AFTER 11:30 AM ON FRIDAY, YOU MAY NOT SHOW UP ON OUR PRINTED LIST AT THE EVENT BUT WILL STILL BE ENTERED TO WIN THE GIFT CARD.

The National Kidney Foundation has an upcoming KEEP Healthy Kidney Screening in Hays, KS. Although pre-registration is not required, it is encouraged. By pre-registering you can skip much of the registration process on the day of the screening. Please provide some basic contact information. This information will not be shared with anyone. Everyone who pre-registers, will be entered to win a gift card upon completion of screening!

--- Saturday, February 10, 2018 at 10:00 am - 2:00 pm (last screening at 1:30 pm)
--- Hays Middle School
--- 201 W 29th Street
--- Hays, KS 67601

What to expect at the event: risk survey, blood pressure check, body mass index measurement (BMI), an opportunity to speak with a healthcare professional, free education materials, and for individuals at risk, an ACR urine test for albumin (a type of protein). Must be 18 years or older to participate. KEEP Healthy is a free program for participants.

General and Medical Volunteers Needed for this event. Visit www.kidney.org/KEEPvolunteerKS for more information.

First Name: *
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Last Name: *
Your answer
Street Address:
Please include apartment and/or suite number if applicable.
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City:
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State:
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Zip Code:
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Email Address: *
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Phone Number: *
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How did you hear about KEEP Healthy?
Please select all that apply.
Would you like to receive additional information from the National Kidney Foundation *
What is your preferred language? *
What time would you like to attend the screening? *
The screening will take approximately 20-30 minutes to complete.
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