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Men’s Health: A Family Affair

Saturday, Sept. 13
10 a.m. to 3 p.m.
Kentucky Center for African American Heritage
1701 W. Muhammad Ali Blvd., Louisville, Ky.

* Indicates required information
Name (First and Last) * 
Email Address * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Gender * 

Birthdate (day/month/year) * 
Phone Number * 
What is your ethnicity? * 
What is your race? (Check all that apply) * 




Do you have a primary care doctor? * 
Do you have health insurance?  * 
Do you use tobacco (including e-cigarettes)?  * 
I would like to register for: * 

*Note (Free prostate cancer screening is for men, ages 50 to 74 who have not had a PSA screening in the past year 
If you registered for a free prostate cancer screening, you must attend the brief discussion “Should you be screened for prostate cancer?” at 1:30 p.m. 
Are you a Norton Healthcare employee?  * 

If Norton Healthcare employee, list your employee ID number 

Please list the names of all those who will be attending  

1st Attendee Name * 
2nd Attendee Name 
3rd Attendee Name 
4th Attendee Name 
How did you hear about this event? * 

If Other, please specify:

When was your last colon cancer screening (colonoscopy or at-home kit)? * 
When was the last time you had a PSA test (prostate)? * 
When was your last mammogram? * 
Authentication * 

If the challenge words are too difficult to read, click here to refresh.
 

If you registered for a free prostate cancer screening, you must attend the brief discussion “Should you be screened for prostate cancer?” at 1:30 p.m.

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