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Empowering Kids to Grow Up Healthy
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Please answer the following questions about your child.
District of Columbia
Date of birth:*
Current School:* (if summer, School entering in Fall)
Current Grade:* (if summer, Grade entering in Fall)
How do you identify your child?*
Is this child Multiracial?*
Who resides in the household with your child?*
Diabetes/High Blood Sugar:
High Blood Pressure:
Asthma or Other Lung Condition:
Musculoskeletal Condition or Injury:
Other Serious Illness:
Please describe any additional medical conditions that may affect your child's participation in an exercise program.
Is your child taking any medication (including prescription and non-prescription)? If yes, please state below.
Primary Source of Healthcare:*
Name of Healthcare Facility:
If your child has a primary physician, please fill in the details below:
Please answer the following questions about yourself.
Relationship to child:
Is the phone number above home, work or cell:*
Is the phone number above home, work or cell:
What is your employment status?
What is your highest level of education?
Does your child qualify for free or reduced-price school lunch program?*
Emergency contact information (In addition to Parent/Guardian above)
Relationship to child:*
Consent for Future Follow up*
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