GoKids Boston

Empowering Kids to Grow Up Healthy

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Participant Registration

ABOUT PARTICIPANT

Please answer the following questions about your child.

First Name:*

Last Name:*

Address:*

City:*

State:*

Zip:*

Date of birth:*

Parent's Phone:*

Gender:*

Male Female

Current School:* (if summer, School entering in Fall)

Current Grade:* (if summer, Grade entering in Fall)

How do you identify your child?*

Asian, Non-Hispanic Asian, Hispanic Black/African American, Non-Hispanic Black/African American, Hispanic Native Hawiian/Pacific Islander, Non-Hispanic Native Hawiian/Pacific Islander, Hispanic Native American/Alaskan, Non-Hispanic Native American/Alaskan, Hispanic White, Non-Hispanic White, Hispanic

Is this child Multiracial?* This is a required field.

Yes No N/A

Who resides in the household with your child?*

Both Parents Single Mother Single Father Grandparent(s) Other

Enter Health History Information*

Enter Parent Guardian Information*

Enter Emergency Contact Information*

Parent Consent*

Yes No

Child Assent*

Yes No

Consent for Future Follow up*

Yes No

Please answer the question below. This is to ensure that this form is submitted by a person rather than a robot.*
Is the University of Massachusetts Boston in Massachusetts? (yes or no)