* = Required Information

Great Progress Member's Name: *  
State: *  
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Making Great Progress against women's health problems and to promote quality health care centers in Rural Areas of Nigeria Registration Form
Please print neaty in black color using capital letters
Event Locaton:  
TEAM NAME:  
TITLE (Mr., Mrs., Ms., Dr.):  
FIRST NAME:  
LAST:  
E-MAIL ADDRESS:  
COMPANY/ORG NAME:  
COMPANY ADDRESS:  
STATE:       CITY:  
ZIP CODE:  
HOME ADDRESS:  
STATE:       CITY:  
ZIP CODE:  
PHONE:       FAX:  

PLEASE ANSWER THESE QUESTIONS CORRECTLY:



SELECT THE RACE /ETHNICITY WITH WHICH YOU MUST CLOSELY IDENTIFY TO HELP VINMABEL WOMEN COMPREHENSIVE HEALTH FOUNDATION BETTER SERVE OUR COMMUNITY AND ITS POPULATION ( PLEASE SELECT ONE)
African American/ black   American Indian/Alasakan Native   Asian   Caucasian/White   
Hispanic/Latino   Pacific Islander   Others   
NOTE: If you are 40 or older and would like an e-mail reminder to get your yearly Physical, Pap smear and Mammogram, please enter the month you would like to be reminded (example 03= March)
I HAVE DIABETES, HEARTH DISEASE, CANCER OR OTHER HEALTH PROBLEMS. MY MOST RECENT DIAGNOSIS WAS: Please name the type of cancer or others!
Date of diagnosis was:
 *WAIVER: In consideration of being permitted to participate in making great progress against women comprehensive health problems, I hereby for myself, my heirs, and my personal preventatives assume any and all risks that might be associated with the event. I further waive, release, discharge, and covenant not to sue VinMabel Woman Comprehensive Health Foundation, its officers, employee, sponsors, organizers, volunteers, or other representatives, or agents or their successors and assigns or the owner of the site for the event or their respective officers, employer or other representatives, or agents or their successors and assigns for any injuries or damages of any kind whatsoever suffered as a result of me and/or my child taking part in the event and any related activities. I also agree to the use of any photo, film, or video tape of the event for any purpose. I also give my full permission for such first aid as deemed necessary to be provided to me or my child on the premises or prior to transport to a hospital for further treatment.
Date: