NextLevel ReSurG KidFit

KidFit Assessment
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com

Select your Program*
Physical Assessment Information
Prayer is the foundation of this KidFit session, Are you opened to allowing your princess or prince? What are your expectations for this season?*
Height *
Weight*

Medical Information
Does your child have any allergies? If so do they have access to an epi pen?*
Any vision problems or head injuries ?*
Has your child ever experienced any epileptic seizures? If so, what are the triggers?*
Any neck, back, knee injuries or surgeries? *
Does your child have Diabetes, or are under treatment for Diabetes?*
If applicable,Please explain previous question
Any chronic or Acute heart conditions?*

YesNo

Disclaimer

Signature*

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Date*

MonthDayYear
Date
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