ACT! Actively Changing Together
Eating Well, Playing More
---------- CHILD'S INFORMATION
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
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Day
Year
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Primary Phone Number
*
Email
*
example@example.com
Address
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Street Address
Street Address Line 2
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Today
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Day
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Date
NumberOfDays
Age
---------- GUARDIAN INFORMATION
Your Name
*
First Name
Last Name
Relation to Child?
*
Please Select
Mother/Father
Grandparent
Guardian
Other
How did you hear of the ACT! Program?
Please Select
Self (decided to on own)
Non-primary car health professional
Primary Care Provider/Office
Community-based organization/Community Healthcare Worker
YMCA Staff
Family or Friend
Employer or employer's wellness program
Insurance Company
Media (new, advertising or social media)
Is your household Spanish speaking?
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Submit
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