GENESIS WELLNESS CHECK REGISTRATION

Beside Evergreen Hotel, Starlight, Ogbomoso | www.genesismedics.ng

08038608376 | 08131254447 | 07056939659 | info@genesismedics.ng

Event Date: October 5, 2025 | Registration Fee: NGN 10,000

SECTION 1: PERSONAL INFORMATION

1. Full Name:

2. Gender:

Male Female Prefer not to say

3. Date of Birth (DD/MM/YYYY):

4. Phone Number:

5. Email Address:

6. School Name:

7. Position:

8. LGA of Residence:

9. Have you made payment yet?

Yes No

10. Mode of Payment:

Bank Transfer POS Cash

I consent to participate in the wellness screening, and I declare that the information provided above is true and correct.

13. Do you have any known chronic conditions?

None Yes (specify):

14. Do you have any allergies?

No Yes (specify):

15. How did you hear about this wellness check?

School Announcement WhatsApp Group Social Media Radio/TV Friend/Colleague Other (please specify):

Signature (Type Full Name):

Date of Submission: