This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range.

The value you provided is outside the suggested range.

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/CARE\d{5}/

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/LUNG\d{5}/

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^\d{2}\-\d{2}\-\d{2}\-\d$/

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9])$?)\s*(?:[.-]\s*)?([2-9]\d{2})\s*(?:[.-]\s*)?(\d{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):?([0-5][0-9])$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/TPHD00\d{3}/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

5u4sPJKc9tsKIhZqJevuD3NJsbA8u5WfJ4kXs7IL4B4PWS3mdXnNyms47p86Ahwp3HYGvadWUvd8w3jtyzXi9jzZh8sstUPPTf

Womens Health Awareness 2023 Online Registration

Please complete the Women's Health Awareness 2023 Registration below.

Thank you!

M-D-Y

In the near future, you will receive a confirmation email with details about time and specific location in the county you specified.

PLEASE NOTE: Due to ongoing Covid-19 concerns, masking is encouraged; however, they are optional.

Email not provided

reset

Yes No

reset

Emails do not match. Please verify.

Home

Cell

Work

Other

reset

Yes No

reset

American Sign Language Interpreter (in-person and virtual)

Closed Captioning (virtual only)

Spanish Interpretation (in-person only)

Handicap parking (in-person only), valid North Carolina handicap placard and/ or license plate required

Do you require one of the following options?
Sign language interpreting and CART services are available upon request to participate in this event. Individuals needing either of these services and/or other reasonable accommodations should contact Lynae Baker (lynae.baker@nih.gov). Requests should be made at least five days in advance. To access Telecommunications Relay Services (TRS), call 711.

* must provide value

American Sign Language Interpreter Closed Captioning

Family/Friend

Social Media

Listserv

Newspaper

Church/Place of worship

Word of mouth

Work

WHA Newsletter

City Transit Ads

Other

Yes

I already receive the emails

reset

OFFERING FREE MAMMOGRAMS

Yes No

reset

Waiver and Release of Liability

I have volunteered and consent to participate in Women's Health Awareness on Saturday, April 15, 2023, on the campus of North Carolina Central University and have agreed to participate in activities of the day which will include, but may not be limited to, participating in exercise demonstrations, Zumba, Line Dancing, Self Defense and cooking demonstration activities.

THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES THAT MAY OCCUR AS A RESULT OF: (1) MY VOLUNTARY PARTICIPATION, (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT, AND (3) OUR NEGLIGENT INSTRUCTION OR SUPERVISION.

I have volunteered and consent to participate in Women's Health Awareness on Saturday, April 15, 2023, in Granville County (location to be determined - you will be notified) and have agreed to participate in activities of the day which will include, but may not be limited to, participating in exercise demonstrations-Zumba, Line Dancing, Self Defense and cooking demonstration activities.

THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES THAT MAY OCCUR AS A RESULT OF: (1) MY VOLUNTARY PARTICIPATION, (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT, AND (3) OUR NEGLIGENT INSTRUCTION OR SUPERVISION.

I have volunteered and consent to participate in Women's Health Awareness on Saturday, April 15, 2023, at Long's Chapel Church, Waynesville, NC and have agreed to participate in activities of the day which will include, but may not be limited to, participating in exercise demonstrations-Zumba, Line Dancing, Self Defense and cooking demonstration activities.

THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES THAT MAY OCCUR AS A RESULT OF: (1) MY VOLUNTARY PARTICIPATION, (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT, AND (3) OUR NEGLIGENT INSTRUCTION OR SUPERVISION.

Assumption of Risk

I recognize that exercise might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. These changes include abnormal blood pressure; injury; fainting; disorders in heartbeat; heart attack; and, in rare instances, death.

By attending this event, I acknowledge that an inherent risk of exposure to COVID-19 (coronavirus) exists in any public place where people are present. By attending the event, I voluntarily assume all risks related to exposure to COVID-19 (coronavirus) and agree not to hold the Women's Health Awareness and The National Institute of Environmental Health Sciences, or any vendor or service provided associated with this event liable for any illness or injury in connection with my attendance at the event.

I understand that as a result of my participation in an exercise program, I could suffer an injury or physical disorder that could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life.

I acknowledge and so accept any and all responsibility and assume all risk of any injury or damage to my person that may arise, whether directly or indirectly as a result of my participation while attending the Women's Health Awareness Conference. I hereby release and discharge the Sponsor and Co-Sponsors of Women's Health Awareness which include: the National Institute of Environmental Health Sciences, The National Institutes of Health, The Durham Alumnae Chapter of Delta Sigma Theta Sorority, Inc., The Durham Alumnae Delta House, Inc. and North Carolina Central University and all of their respective agents, contractors, and employees and its respective officers and employees from all claims, damages, and liability whatsoever that may result from my injury or death, accidental or otherwise, during or arising from my attendance at the Women's Health Awareness Conference.

I recognize that exercise might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. These changes include abnormal blood pressure; injury; fainting; disorders in heartbeat; heart attack; and, in rare instances, death.

By attending this event, I acknowledge that an inherent risk of exposure to COVID-19 (coronavirus) exists in any public place where people are present. By attending the event, I voluntarily assume all risks related to exposure to COVID-19 (coronavirus) and agree not to hold the Women's Health Awareness and The National Institute of Environmental Health Sciences, or any vendor or service provided associated with this event liable for any illness or injury in connection with my attendance at the event.

I understand that as a result of my participation in an exercise program, I could suffer an injury or physical disorder that could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life.

I acknowledge and so accept any and all responsibility and assume all risk of any injury or damage to my person that may arise, whether directly or indirectly as a result of my participation while attending the Women's Health Awareness Conference. I hereby release and discharge the Sponsor and Co-Sponsors of Women's Health Awareness which include: the National Institute of Environmental Health Sciences, The National Institutes of Health, The Durham Alumnae Chapter of Delta Sigma Theta Sorority, Inc., The Durham Alumnae Delta House, Inc. and Granville County location and all of their respective agents, contractors, and employees and its respective officers and employees from all claims, damages, and liability whatsoever that may result from my injury or death, accidental or otherwise, during or arising from my attendance at the Women's Health Awareness Conference.

I recognize that exercise might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. These changes include abnormal blood pressure; injury; fainting; disorders in heartbeat; heart attack; and, in rare instances, death.

By attending this event, I acknowledge that an inherent risk of exposure to COVID-19 (coronavirus) exists in any public place where people are present. By attending the event, I voluntarily assume all risks related to exposure to COVID-19 (coronavirus) and agree not to hold the Women's Health Awareness and The National Institute of Environmental Health Sciences, or any vendor or service provided associated with this event liable for any illness or injury in connection with my attendance at the event.

I understand that as a result of my participation in an exercise program, I could suffer an injury or physical disorder that could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life.

I acknowledge and so accept any and all responsibility and assume all risk of any injury or damage to my person that may arise, whether directly or indirectly as a result of my participation while attending the Women's Health Awareness Conference. I hereby release and discharge the Sponsor and Co-Sponsors of Women's Health Awareness which include: the National Institute of Environmental Health Sciences, The National Institutes of Health, The Durham Alumnae Chapter of Delta Sigma Theta Sorority, Inc., The Durham Alumnae Delta House, Inc. and Western North Carolina Carolina (Long's Chapel Church) and all of their respective agents, contractors, and employees and its respective officers and employees from all claims, damages, and liability whatsoever that may result from my injury or death, accidental or otherwise, during or arising from my attendance at the Women's Health Awareness Conference.

Consent to Photograph

I also acknowledge my agreement that I may be videotaped, audio recorded and/or photographed during this event, and all component which may be used and modified and/or recorded for any and all uses, included but not limited to advertisements and marketing without any compensation or perpetuity. Expiration date or an expiration event: 100 years from today's date.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND/OR AN AUTHORIZED INDIVIDUAL HAS EXPLAINED ALL ASPECTS OF THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY.

(IF YOU NEED ASSISTANCE OR HAVE QUESTIONS, PLEASE CONTACT US AT WHA@NIEHS.NIH.GOV OR 919-541-3852.)

BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST ALL SPONSORS AND COSPONSORS OF THE WOMEN'S HEALTH AWARENESS CONFERENCE FOR YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS.

Add signature

PRIVACY STATEMENT

The information requested in this documentation is authorized to be collected pursuant to the Public Health Service Act. Providing the requested information is voluntary, however, declining to provide any or all of the requested information may preclude you from attending the event. The principal purpose for which the information will be used is registration. The information you provide will be included in a Privacy Act system of records, and will be used and may be disclosed for the purposes and routine uses described and published in the following System of Records Notice (SORN): 09-25-0012 Clinical Research: Candidate Healthy Volunteer Records, HHS/NIH/CC

M-D-Y

PLEASE NOTE: Every effort is made to ensure that your privacy and confidentiality are maintained. All information provided will be kept confidential to the extent provided by federal, state, and local laws.

PLEASE CLICK SUBMIT TO CONTINUE WITH REGISTRATION

Lead Sponsor: National Institute of Environmental Health Sciences (NIEHS), Clinical Research Branch, Office of Human Research and Community Engagement

Co-Sponsors: Durham Alumnae Chapter of Delta Sigma Theta Sorority Inc., Durham Alumnae Delta House Inc., and North Carolina Central University Department of Public Health Education

You have selected an option that triggers this survey to end right now. To save your responses and end the survey, click the button below to do so. If you have selected the wrong option by accident and do not wish to leave the survey, you may click the other button below to continue, which will also remove the value of the option you just selected to allow you to enter it again and continue the survey.

The response has now been removed for the last question for which you selected a value. You may now enter a new response for that question and continue the survey.