Goshen Health | Goshenhealth.com

Registration Form

Please complete one registration form for all participants living in your household.

All fields required

ActiveTrac Form Ignore first form field. First Name (required)Last Name (required)EmailAddressCity State ZIPPhone Is this participant Healthcare Provider NameOn average, how many minutes of activity does this person get daily?

By checking this box, I/we acknowledge that I/we have read both the Liability Waiver and the Patient Privacy Notice

Liability Waiver | Patient Privacy Notice

A typed signature is required for each household member age 18 and up

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Questions about this form?

Please call (574) 364-2496