Healthy Weight And Your Child
A Healthy Eating and Active Living Program brought to you by the YMCA
ABOUT YOU - ADULT DETAILS
Name
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Contact Method
*
Email
Mobile - Call
Mobile - Text
Home Phone
How did you hear about the program?
*
Current/Former Program Participant
Doctor/Other Health Care Professional
Employer
Family/Friend/Word of Mouth
Health Insurance Company
Media/Marketing
Screening Event/Health Fair
Y Staff Member/Volunteer
Other
Are you and your family members of the Y?
*
Yes
No
PARTICIPANT/CHILD DETAILS
Child Name
*
First Name
Last Name
Child's Nickname/Preferred:
*
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Sex
*
Male
Female
(self-reported) Height in inches for Child (ex: 5 feet = 12 inches X 5 = 60 inches)
*
(self-reported) Weight for Child (lbs)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your Child of Hispanic, Latino (a), or Spanish Origin?
*
Yes
No
Prefer not to answer
What is your child's race? (Check all that apply)
*
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
A race not listed here
Prefer not to answer
Is your child eligible for free or reduced school lunch?
*
Yes
No
IN THE PAST 12 MONTHS, did anyone in this household receive Food Stamps or a Food Stamp benefit card? Include government benefits from the Supplemental Nutrition Assistance Program (SNAP - Do NOT include WIC or the National School Lunch Program).
*
Yes
No
THANK YOU!!
All enrollees please hit the submit button. The next page is for YMCA Staff only.
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Submit
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YMCA Staff Only:
Does the child qualify based on the self-reported height and weight?
Yes
No
Patient Contact Log
Patient is: Contacted, Waiting on Medical Clearance, Cleared to Participate, Waitlisted, Enrolled, Declined, Completed
Contacted
Waiting on Medical Clearance
Cleared to Participate
Waitlist
Enrolled
Declined
Withdrew
Completed
Class / Cohort Name
Class Location
Cohort Start Date
-
Month
-
Day
Year
Date
Cohort Finish Date
-
Month
-
Day
Year
Date
Below forms are signed and on file:
Medical Clearance Form
Consent and Release from Liability
Authorization for Use and Disclosure of Health Information
Authorizations for Release of Information to Health Care Provider
Submit
Should be Empty: