District 47 – Wellness Screening Registration Form ***This form works best with Google Chrome*** Company Name: * Crystal Lake School District 47 Screening Location: * Bernotas Middle SchoolCanterbury Elementary SchoolCORE CenterCoventry Elementary SchoolGlacier Ridge Elementary SchoolHannah Beardsley Middle SchoolHusmann Elementary SchoolIndian Prairie Elementary SchoolLundahl Middle SchoolNorth Elementary SchoolSouth Elementary SchoolTJA Bus DepotWest Elementary SchoolWoods Creek Elementary School Hannah Beardsley screening is on: Tue 03-03-2026 6AM–8:30AM Bernotas screening is on: Wed 03-04-2026 6AM-8:30AM Glacier Ridge screening is on: Thu 03-05-2026 6:30AM–9AM North screening is on: Fri 03-06-2026 6:30AM–9AM TJA Bus Depot screening is on: Mon 03-09-2026 4AM-5AM For TJA Employees Only Coventry screening is on: Tue 03-10-2026 6:30AM–9AM Indian Prairie screening is on: Wed 03-11-2026 6:30AM–9AM Woods Creek screening is on: Thu 03-12-2026 6:30AM–9AM Canterbury screening is on: Fri 03-13-2026 6:30AM–9AM Lundahl screening is on: Tue 03-17-2026 6AM–8:30AM CORE screening is on: Wed 03-18-2026 7AM-9AM South screening is on: Thu 03-19-2026 6:30AM–9AM West screening is on: Fri 03-20-2026 6:30AM–9AM Husmann screening is on: Tue 03-31-2026 6:30AM–9AM Name: * Legal First Last: * Legal Last Status: * Employee Family Member Do you have District 47 insurance? * Yes No - $99 Your insurance status will be validated before the screening. Family member status: * SpouseDependent (18 and over) Street address: * City: * State: * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip: * Daytime phone#: * Alternate phone#: Birth date: * Age: Sex: * Male Female Other Email Address: * Tests Requested Please check each additional test below you would like to add to your basic screening Note: Basic screening includes: CMP, CBC, & Lipid Panel Note: Additional lab tests may also be added or changed, the day of your screening Additional tests: PSA (prostate cancer) - $47 Homocysteine (stroke/heart attack) - $65 CA-125 (ovarian cancer) - $50 C-Reactive protein (stroke/heart attack) - $45 Thyroid panel - $47 Osteoporosis testing (urine test) - $58 Arthritic profile - $58 Blood typing - $40 H. Pylori (ulcer/gastritis) - $55 Vitamin D levels - $47 Vitamin B-12 - $45 Hepatitis C - $65 Covid Antibody - $89 Iron - $40 A-1C - $47 Testosterone - $47 All screenings include, height, weight, blood pressure, and body composition analysis Click here for lab test explanations Do you have any of the following? Diabetes High Blood Pressure Thyroid Disease Heart Disease Lung Disease Are you taking any medications related to the above? Would you like to pay now or at the screening? * NowAt screening Total charges: Total charges: $ Total pre-paid charges: Total pre-paid charges: $ After payment, please click 'Return to Community Health Works' to schedule an appointment Captcha Please remember to fast for 8 hours. Black coffee, water, and plain tea are allowed. Once you click submit please wait for the appointment scheduling form to appear... If you are human, leave this field blank.
