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Saturday, October 14, 20179AM - 3PM Ford Field - Gate G

MICHIGAN INSTITUTE OF UROLOGY

FREE Men’s Health Screenings Including PSA, Testosterone, Glucose, Cholesterol,

HDL, LDL, Triglycerides, Uric Acid, Liver Function Tests, Vital Measurements, Body Fat Percentage and

Waist Measurement, Vision, Dental, Hearing, HIV Testing, Depression, Skin Cancer Screenings and more!

Live Music | Ask the Healthcare Expert Family Friendly Event | Giveaways

Men’s Health & Sports Displays | Free Haircuts Flu Vaccines | On-Field Fitness Classes

Opportunity to kick a field goal on Ford Field!

R E G I S T R A T I O N F O R M

To pre-register, please visit TheMensHealthEvent.com

or return this form to:

MIU Men’s Health Foundation20952 E. 12 Mile Road, Suite 200 | St. Clair Shores, MI 48081

info@MIUMensHealthFoundation.org | Fax: (586) 774-2633

_________________________________________________________________Name:

_________________________________________________________________Address:

_________________________________________________________________City, State, Zip:

_________________________________________________________________Phone:

_________________________________________________________________Email:

_________________________________________________________________Date of Birth:

Blood Draw Reservation Time: (hourly from 9am – 3pm)

9AM - 10AM 12PM - 1PM 10AM - 11AM 1PM - 2PM 11AM - 12PM 2PM - 3PM

Have you attended a prior year’s Men’s Health Event? YES or NO

If yes, did you receive follow-up healthcare as a result of your health screenings? YES or No

How did you hear about the event?

_________________________________________________________________

Church affiliation __________________________________________________

Seventh Annual

MEN’S HEALTHEVENT

As a 501(c)(3) non-profit organization, MIU Men’s Health Foundation is dedicated to men’s health advocacy and the awareness, education, research

and treatment of prostate cancer and men’s health related issues.

MICHIGAN INSTITUTE OF UROLOGY

20952 E. Twelve Mile, Suite 200 St. Clair Shores, MI 48081 (586) 443-4272info@MIUMensHealthFoundation.org MIUMensHealthFoundation.org

M I C H I G A N

M I C H I G A N

M I C H I G A N

M I C H I G A N

Premier Healthcare Partner

Premier Healthcare Partner

BOOTHSDozens of nonprofits, healthcare organizations and sponsors will have booths along Adams Road inside Ford Field to provide free educational materials, giveaways, demonstrations and more!

ASK A HEALTHCARE EXPERTHave a question you would like to ask a healthcare expert one-on-one? Visit one of the “Ask the Healthcare Expert” tables, and get your questions answered! Healthcare experts will be available for questions all day long, and have varying areas of expertise.

ASK A PHARMACISTHave questions about your prescription medication, over-the-counter medication or potential interactions? Visit the “Ask a Pharmacist” table, and get your questions answered! Be sure to bring your medication or a list of medications.

ON-FIELD ACTIVITIES Please join us for fun and interactive fitness activities on Ford Field. Wear comfortable workout clothes and gym shoes for all activities. For yoga classes, please bring a yoga mat if you own one.

PARKINGConvenient parking is available at Gate G for $4 per vehicle.Closest Smart Bus stop: 36th District Court 421 Madison Avenue, Detroit, MI 48226Closest Q Line stop: Montcalm Street StationPlease note that you must enter at Gate G off of St. Antoine Street. All other entrances will be closed.

FUND-A-MANDo you want to help support The Men’s Health Event? Your tax-deductible contribution of $20 directly provides the following screenings for one man at the event: Prostate-specific antigen (PSA), Testosterone, Glucose, Cholesterol, HDL, LDL, and Triglycerides, Uric Acid, and Liver Function Tests. To make your donation today, please visit www.miumenshealthfounation.org.

MICHIGAN INSTITUTE OF UROLOGY

Register Today at TheMensHealthEvent.com

WAIVER AND RELEASE AGREEMENT: I understand that my consent to this Waiver and Release Agreement (“Agreement”) is given in consideration for being allowed to participate in the Men’s Health Event 20XVII on October 14, 2017 and its affiliated activities and events (“Event”). I hereby covenant that I am in good physical condition and am solely responsible for my personal health, safety and personal property. I understand that the Event is a poten-tially hazardous activity and I hereby assume, voluntarily, full and complete responsibility for any injury, accident, or loss that may occur during my participation in the Event or while on Event Premises. I, for myself, my heirs and next of kin, administrators and executors, hereby unconditionally and irrevocably release and hold harmless, and covenant not to file suit against, Michigan Institute of Urology Men’s Health Foundation, Men’s Health Event 20XVII, Michigan Institute of Urology, P.C., Ford Field Management, LLC, Ford Field Condominium Association, Ford Field Management Company, Ford Field Enterprises, DLI Properties, LLC, DLI Properties, Inc., DLI Management, Inc., DLI Parking, LLC, DLI Office Realty, LLC, DLI Entertainment, LLC, DLI Parking Realty, LLC, The Detroit Lions, Inc., Detroit Lions Charities, Detroit Lions Properties, FFP Investment Company, LLC, S.A.F.E. Management, LLC, City of Detroit, Downtown Detroit Development Authority, Detroit/Wayne County Stadium Authority, Wayne County, any and all event sponsors, organizers, volunteers and their respective parents, subsidiaries, successors, assigns, affiliates, suppliers, licensees, and the respective directors, officers, board members, employees, shareholders, councilper-sons, contractors and agents of same (collectively, “Released Parties”) for any and all injuries, damages, claims or losses, now existing or hereafter arising, known or unknown, which I, my minor children attending the Event, and/or representatives may sustain while participating, in any way, in the Event or while on Event Premises, regardless of the form or action or basis of the claim, whether in contract or tort, including claims arising from or relating to performance of medical services or disbursement of over-the-counter medication by any of the Released Parties at the Event, strict liability and sole negligence of the Released Parties. I understand that I am responsible for any and all medical coverage for myself, my minor children, and/or representatives throughout the duration of the Event. I further hereby assume, voluntarily, full and complete responsibility for any injury, accident, or loss that may occur as a result of my voluntary participation in any and all men’s health screening and associated tests at the Event. I further acknowledge and warrant that I hereby unconditionally and irrevocably release and hold harmless, and covenant not to file suit against any and all of the Released Parties relative to and/or reliance upon the tests, results, consultation, advice (medical, professional or otherwise) and information relayed, arising out of any affiliated men’s health screening, associated tests and informational sessions at or from the Event. I understand and personally assume the risk and consequences of any affiliated Men’s Health Event screening and associated tests from the Event. By signing this Agreement, I consent to the use and disclosure of my Protected Health Information obtained at, or as a result of, the Event for treatment and health care operations. I further understand that my testing and screening results may be used for medical research, test validation, or education, after personal identifiers are removed and all Protected Health Information is de-identified. Refusal to permit the use of my data for research will not affect my test result(s). I can withdraw my consent at any time by sending a written notice of revocation of the consent to Michigan Institute of Urology Men’s Health Foundation. The undersigned agrees not to sue any of the Released Parties for any matter released under this Agreement and to pay the Released Parties’ attorneys’ fees and costs resulting from a breach of this Agreement by the undersigned. The undersigned agrees that if anyone else sues any of the Released Parties related to the actions of the undersigned while on the premises at Ford Field, the undersigned will indemnify and hold harmless the Released Parties against all damages, costs and their attorneys’ fees. The undersigned further agrees that (a) no promise, inducement or agreement not herein expressed has been made to the undersigned; (b) this Agreement contains the entire agreement between the parties hereto; (c) this Agreement may not be modified, except in a written instrument signed by an authorized representative of the Released Parties; and (d) if any portion of this Agreement is held invalid, the balance shall continue in full force and effect.

PHOTOGRAPHIC RELEASE: I further give my full consent and permission to the Michigan Institute of Urology Men’s Health Foundation, Men’s Health Event 20XVII, Michigan Institute of Urology, P.C., its affiliates, sponsors, succes-sors, assigns and licensees the irrevocable right to use, for any purposes whatsoever and without any compensation, any photographs, videotapes, audiotapes and/or other recordings of me, my minor children and/ or representatives that are made during the course of the Event.

This Waiver and Release Agreement and Photographic Release shall be construed under the laws of the State of Michigan. I understand that I have given up substantial rights by signing this Waiver and Release Agreement and Photographic Release, and have done so voluntarily without any inducement, assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of liability to the greatest extent permitted by law.

Check this box if you DO NOT Authorize the MIU Men’s Health Foundation to contact you after the Event regarding results and follow up care..

_______________________________________________________________________________ Signature of Participant (18+)

_______________________________________________________________________________Printed Name Date

MIU Men’s Health Foundation is proud to present the seventh annual Men’s Health Event 20XVII on Saturday, October 14, 2017 from 9AM-3PM at Ford Field. This FREE event will give men a better understanding of how to stay healthy, free health screenings at a $1,800 value to assess their current health, and information about advances in healthcare. This is the only event of its kind that offers the most in-depth blood panel screening available to men over 18, regardless of health insurance coverage.

EVENT DETAILS• “Ask a Healthcare Expert” and

“Ask a Pharmacist” areas available• Opportunity to kick a field goal on

Ford Field • Live music by The Session Band• Men’s health & sports displays• Food and beverages available for purchase• On-field activities including Quarterback

Challenge, Pass & Kick and The Drive Challenge• Bring your kids and spouse to this family-

friendly event!

FREE HEALTH SCREENINGSHealth screenings are available to men ages 18 and over, regardless of health insurance. You do not need to fast for the blood draw.

• Prostate Specific Antigen (PSA)• Testosterone• Glucose• Cholesterol, HDL, LDL, Triglycerides• Uric Acid• Liver Function Tests• Vital Measurements• BMI Testing/Body Fat Percentage• Depression Screening• Vision Screening• Dental Screening and Oral Examinations (available until 2PM)• Hearing Screening (limited availability)• Skin Cancer Screening• HIV Testing

REGISTRATION DETAILS Register and reserve your blood draw time slot today! Time slots are available hourly from 9am-3pm. Screenings are available to men over 18, health insurance is NOT required. Please bring a valid picture ID to event for confirmation. Same day registration is available.