AnnualHealthFairRegistrationForm 2011 by xm8GKgWK

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									                                                             The Hindu Temple
                                                                44955 Cherry Hills Road, Canton, MI 48188
                                                                                    Phone: (734) 981-8730
                                                                                   www.thehindutemple.org


        Eighth Annual Health Fair on Sunday April 03, 2011
                                 9:00 AM to 1:00 PM

                             Patient Information


First Name:

Middle Initial:

Last Name:

Date Of Birth (MM/DD/Year)_________________ Sex ____Male___Female

Address 1:

Address 2:

City:                                         State:                 Zip:

Home Phone:

Cell Phone:

                         Emergency Contact Information:

First Name:

Last Name:

Home Phone:

Cell Phone:

         If you have any question, please call Jatin Desai at (734) 459-8583.


                             A Non-Profit Tax Exempt Organization
                                     Tax ID: 38-2699933

								
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