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Senior Health Night at Segra Park on May 12th, 2026
Please fill out the form to register for the event!
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1.
Complete this form to learn more about us.
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Name
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Address
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City/Town
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State/Province
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ZIP/Postal Code
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Email Address
Phone Number
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2.
Are you a current CenterWell patient?
(Required.)
Yes
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3.
How did you hear about this event?
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Newspaper
Radio
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Friend/referral
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Current Patient
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4.
Are you interested in:
Free Activities (bingo, crafts, wellbeing classes)
Free VIP tour of our doctor's office
Free information on CenterWell
Other (please specify)
None of the above
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5.
Do you authorize CenterWell to contact you? (This includes notifying you about upcoming events and free activities.)
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