Cleveland Clinic Minority Men's Health Fair Sign Up Form

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Email Address:

Phone Number:

Date of Birth:

Last 4 of SSN:

Gender:

Ethnicity:

Location:

Have you attended the health fair in the past?

If yes, please let us know what you liked best and least:

How did you hear about the health fair?

If "other" please let us know how you heard about the health fair:

What screenings are you interested in? Check all that apply.*

If "other" please indicate what other screenings you'd be interested in:

Can we contact you for research?

If Yes, Indicate the best way to reach you:

Please send me additional information from Cleveland Clinic:

More Information

For more information about the Minority Men's Health Fair, please visit our website.