GoKids Boston

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*