Dear Parent:

We are writing to invite your child/adolescent to take part in a heart screening provided by The Children's Hospital of Philadelphia at the String Theory School on Large and Dyre Streets. This screening is designed to find children and teenagers who have an undiagnosed or silent heart condition and who may be at risk for a cardiac arrest, an event that causes the heart to suddenly quiver and stop beating. This screening is open to healthy children/adolescents without any known heart problems.

If you agree to let your child take part in this study, you can register your child for the screening event and choose an appointment time. At or before the screening event, you will need to complete a Heart Health Questionnaire . This questionnaire will be asking you questions regarding your child's personal health history and activity levels as well as questions regarding your family history. This may take up to 10 minutes to complete. You must give your permission, or consent, for your child to take part in the screening event. Parents are encouraged to accompany their child, which is required for those 12 years of age and under. A signed consent form and filled out Questionnaire can be sent with those 13 years of age and over.

We will ask your child to:

What are the benefits of taking part? Your child will receive heart tests and an evaluation by a Children's Hospital pediatric heart doctor. You may learn important information about your child's heart health. We will tell you right away if we find any serious heart problems or if your child needs more testing.

This study visit will take about 60 minutes. Neither you nor your insurance company will be charged for any testing performed at the screening. If you have any questions, please call the doctor in charge of this study, Dr. Victoria Vetter at 267-426-6603, or the Youth Heart Watch Coordinator, Zane Schultz, at 267-426-7389.

Thank you.

Sincerely,

Victoria L. Vetter, M.D.
Division of Cardiology at The Children's Hospital of Philadelphia

Study Registration Form: Part 1

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INSTRUCTIONS

Only children/adolescents ages 5-19 years old with no known heart problems are eligible to participate in this screening.

Appointment Times: Below are the lists of appointment times for the Heart Health Screening Study. You may register up to 6 children at this time. You will be able to print this page to keep for your records. You are required to complete a questionnaire at the screening.

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Appointment Information
Contact Phone #
Contact E-mail
Choose a Screening Location
Choose an Appointment Time for Each Child/Adolescent
Child/Adolescent First Name Child/Adolescent Last Name Appointment Time
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Security Challenge (please type the word(s) below)

For additional questions or problems contact: Zane Schultz, Youth Heart Watch Coordinator, at The Children's Hospital of Philadelphia, 267-426-7389 or e-mail youthheartwatch@email.chop.edu.