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YOUNG CHAMPIONS Heart Screening Registration
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"Young Champions" Heart Screening Registration

Registration for our community-based Young Champions Heart Screening Clinics are on a first come, first serve basis, with emphasis on Clark County residents. Weekly screenings are available at PeaceHealth Southwest for $50, which include a $25 donation to support future screening events in our community.

If you would like to register your child for our weekly screening clinic at PeaceHealth Southwest Medical Center, please register online (see form below) to sign up. A representative of the PeaceHealth Southwest Heart & Vascular Center will be in touch to confirm your registration, and please allow us a few days to process your request.

  • Registration for the Feb. 23, 2013 screening clinic opens on Jan. 2, 2013.

Students must have a completed parent consent form and health history questionnaire to participate. You may download these documents, or call for a mailed copy. Download "Young Champions" Consent Form (required) Download "Young Champions" Health History Questionnaire (required)
* Indicates required information
Student First Name * 
Student Last Name * 
Student Date of Birth   Calendar (mm/dd/yyyy)
Student Gender 
School Name/Type of Sport 
Parent/Legal Guardian First Name * 
Parent/Legal Guardian Last Name * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Email Address (not required, but recommended for a quicker response) 
Telephone Number * 
Authentication * 

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