InBody Testing 

Person Filling Out Form: 

First Name 

Last Name 

Relationship to person with Down Syndrome

Please select... Mother Father Guardian Sibling Caregiver

Phone

Email

Address

City

State

Zip

Person With Down Syndrome

First Name

Last Name

Birthdate

The InBody is not recommended for those who have a pacemaker or who are pregnant without doctor approval:

I have read and understand the above statement

Have you completed an InBody assessment or similar body composition assessment before?

YesNo

Please indicate who will be completing the InBody assessment:

Self-Advocate only ($25)Myself (Supporter Only) ($25)Self-Advocate & Supporter ($40)2 or More Supporters + Self-Advocate ($50)

Any questions or comments prior to testing?

 

Payment Information

Name on Card

Card Number

MM

YY

Code

Is your billing address different than your shipping address?

NoYes

Complete Billing Address

Address

City

State

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

Zip

I agree to support this mission further by covering my 3% credit card processing fee

Credit Card Fee Amount 

Total Amount

Primary Campaign