GoKids Boston

Empowering Kids to Grow Up Healthy

Participant Registration

ABOUT PARTICIPANT

Please answer the following questions about your child.

Gender:*

How do you identify your child?*

Is this child Multiracial?*

Who resides in the household with your child?*

Heart Disease:

Diabetes/High Blood Sugar:

High Blood Pressure:

Seizure:

Asthma or Other Lung Condition:

Cancer:

Musculoskeletal Condition or Injury:

Other Serious Illness:

Allergy:

Primary Source of Healthcare:*

If your child has a primary physician, please fill in the details below:

Please answer the following questions about yourself.

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)

Parent Consent*

Child Assent*

Consent for Future Follow up*