Registration for Championship Health - Men's Wellness Conference

REGISTER TODAY!

UnitedHealthcare, Primary Health Solutions & The HealthCare Connection invite you to join us for a fun-filled day of:

- Free Health Screenings
- Health Workshops
- Door Prizes
- Free Game & Drink Tickets
- Sports & Entertainment Celebrity Panel Discussion
- Breakfast and Lunch
- Individual Health Counseling

Win an IPhone 6, IPad or Bengals game tickets

Saturday, November 1, 2014

9:00 am - 12:30 pm

Dave & Buster's TriCounty
11775 Commons Dr., Cincinnati, OH 45246

REGISTRATION IS FREE FOR All PARTICIPANTS

Questions may be directed to Dana Harmon at 513-454-1460 or danah@myprimaryhealthsolutions.org or Jacqueline Schmucki at 513-483-3081, jacquelines@healthcare-connection.org

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* 1. First Name

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* 2. Last Name

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* 3. Street Address

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* 4. City

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* 5. State

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* 6. Zip Code

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* 7. Email Address

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* 8. Home Telephone

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* 9. Mobile Telephone

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* 10. Emergency Contact Name

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* 11. Emergency Contact Telephone Number

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* 12. Are you a patient of Primary Health Solutions or The HealthCare Connection?

Yes

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* 13. If you answered yes to the above question, which location?

Primary Health Solutions - Middletown Health Center, 1036 S. Verity Parkway, Middletown

Primary Health Solutions - Bever Pavilion, 210 South 2nd St., Hamilton

Primary Health Solutions - Hamilton West, 903 N.W. Washington Blvd., Suite A, Hamilton

The HealthCare Connection - Lincoln Heights Health Center, 1401 Stefen Avenue, Cincinnati

The HealthCare Connection - Mt. Healthy Family Practice, 8146 Hamilton Avenue, Cincinnati

The HealthCare Connection - Forest Park Health Center, 924 Waycross Rd., Cincinnati

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* 14. What category best describes your age?

18 - 29

30 - 39

40 - 49

50 - 59

60 - 69

70 - 79

80 or older

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* 15. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic/Latino

White / Caucasian

Other (please specify)

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* 16. What areas of health are of interest to you?

Asthma

Bronchitis

Colon Cancer

Diabetes

Depression

Heart disease

Hepatitis

High Blood Pressure

High Cholesterol

HIV/AIDS

Lung Disease

Mental Health

Prostate Cancer

Sexually Transmitted Disease

Shortness of Breath

Skin Conditions

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* 17. What is the best method of communicating with you?

Phone Call

Email message

Postcard

Letter

Text message

Facebook

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* 18. Do you have any dietary restrictions?

Yes

If yes, please describe.

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* 19. How did you hear about the conference?

Email advertisement

Facebook

Flyer or sign at a Primary Health Solutions

Flyer or sign at The HealthCare Connection

Newspaper story

Newspaper advertisement

Newspaper website

Invitation mailed to my home

Radio Talk Show

Radio Advertisement

Radio Website

Television News Show

Television Advertisement

Television website

Primary Health Solutions website

The HealthCare Connection website

Informed by a friend or relative

Referred by (Write name below of person who referred you.)

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* 20. Let us use your story in a men's health marketing campaign to inspire other men in greater Cincinnati. We'll pay you $50. Are you willing to have your story recorded (one of 5 men) and have your picure taken at the conference for use in a marketing campaign?

Yes

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* 1. First Name

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* 2. Last Name

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* 3. Street Address

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* 4. City

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* 5. State

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* 6. Zip Code

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* 7. Email Address

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* 8. Home Telephone

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* 9. Mobile Telephone

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* 10. Emergency Contact Name

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* 11. Emergency Contact Telephone Number

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* 12. Are you a patient of Primary Health Solutions or The HealthCare Connection?

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* 13. If you answered yes to the above question, which location?

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* 14. What category best describes your age?

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* 15. Which race/ethnicity best describes you? (Please choose only one.)

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* 16. What areas of health are of interest to you?

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* 17. What is the best method of communicating with you?

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* 18. Do you have any dietary restrictions?

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* 19. How did you hear about the conference?

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* 20. Let us use your story in a men's health marketing campaign to inspire other men in greater Cincinnati. We'll pay you $50. Are you willing to have your story recorded (one of 5 men) and have your picure taken at the conference for use in a marketing campaign?

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THANK YOU!