Jain Center Of Southern California Wellness Challenge

  Registration Form
 		 
  Fields marked with * are required
FirstName * Middle Initial Last Name *
Gender *

  Month Year
Birth Date*
Address*  
Street(and Apt#)
City, State - Zip  ,  - 
   
Phone
Email*
   
Were you born in USA?*

             

Occupation





 

Agree to particpate in the program 

I would like to be part of the Wellness Challenge at Jain Center of Southern California (JCSC), and allow JCSC to take and/or use my base line Biometric readings / measurement for Blood Pressure, Body Mass Index, Height-Weight, Blood Sugar, Hemoglobin, Lipid Profile etc. and permitting to be used for Collective Analytics/statistical purpose. I understand that my participation is voluntary, and that JCSC is not a health care provider, and is a nonprofit organization, and is doing this activity for the betterment of the community. I will consult my Doctors for any health matters that require medical advice. JCSC will make every effort to keep my data confidential. I will hold harmless JCSC, its officers, sponsors, volunteers and supporters for any claim arising out of my participation in this Wellness Challenge.

Please enter all the numbers or characters you see below including those in the photograph.