FREE PHYSICALS DAY ONLINE REGISTRATION (ENGLISH VERSION)
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1. Free Physicals Day Online Registration

PLEASE COMPLETE THE FOLLOWING SECTION TO REGISTER YOUR CHILD FOR AN APPOINTMENT FOR A FREE SPORTS, SCHOOL, OR CAMP PHYSICAL ON AUGUST 14TH 9:30AM - 1:00PM.

CLICK "DONE" WHEN COMPLETE.

* Please Note: Children are eligible for free health services at the Jeanie Schmidt Free Clinic if they have no medical insurance and a household income of less than twice the federal poverty level. Parent/legal guardian must be present with child(ren) on Free Physicals Day.

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1. Student's Name:

Student's Name:

2. Student's Date of Birth:

	MM		DD		YYYY
MM/DD/YYYY	Student's Date of Birth: MM/DD/YYYY Month	/	Day	/	Year

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3. Contact Information

Contact Information Parent/Legal Guardian's Name:
Address:
City/Town:
ZIP:
Email Address (if applicable):
Phone Number:

4. Primary Language Spoken at Home:

Primary Language Spoken at Home:

5. Does student have medical insurance?

Does student have medical insurance? Yes

6. Family Income:

Family Income:

7. Number of Family Members in your Household:

Number of Family Members in your Household:

YOU WILL BE CONTACTED BY THE JSFC WITHIN THE NEXT FEW DAYS TO SCHEDULE AND CONFIRM YOUR APPOINTMENT.

FOR MORE INFORMATION ABOUT FREE PHYSICALS DAY OR QUESTIONS REGARDING REGISTRATION, PLEASE CALL 703-481-8160 OR VISIT US ONLINE AT WWW.JSFREECLINIC.ORG

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