Jain Center Of Southern California Wellness Challenge

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

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




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.

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