Kids Off the Kouch (Pilot Period)

Kids Off the Kouch Participation (Pilot Period)

Tulare Hospital & Community Health Foundation
Kids Off the Kouch Wellness Program during the pilot period, beginning March 23, 2024 through April 20, 2024.

Child and their approved exercise partner will attend the health screening on March 23, 2024 at the Adventist Health Hillman Health Clinic at 2059 N, Hillman St. – Tulare, Ca 93274 (559-605-0090).
Participant Information
Child/Participant Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Guardian / Parents Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
E-mail
example@example.com
Health Information
Date of Last Doctor's Visit:

MonthDayYear
Date
Reason for Last Doctor's Visit:
Known/diagnosed illness, allergies, health issues:
On medication?
If so, please list:
Physician Information
Name of Physician
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone Number
Format: (000) 000-0000.
I hereby authorize and approve my child [named above] to participate in the Kids Off the Kouch Wellness Program during the pilot period, beginning March 23, 2024 through April 20, 2024.
I understand that my child and their approved exercise partner will attend the health screening on March 23, 2024 at the Adventist Health Hillman Health Clinic at 2059 N. Hillman St, Tulare, CA 93274 (559-605-0090)
Signature
Important Notes
- Prizes and awards are not a guarantee and are based on participation, documentation of hours exercised, and most improved progress.
- Regular K.O.T.K. will begin June 1, 2024, and run to June 1, 2025. Grand Prize for the regular session will be two entry passes to Disneyland (Anaheim, Ca.) Winner will be responsible for their own transportation to and from and all other expenses in connection with the trip.
Should be Empty:

Kids Off the Kouch Participation (Pilot Period)