UMass Boston / GoKids / Clinician Referral

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GoKids Participant Registration

Select Program Please select a program from the following options. If you are not sure which program to enroll your child into, please do not select anything.

General Membership:

Community Program:

Research Programs:

Clinician Referral:

Participant Information Please answer the following questions about your child:

First name:*

Last name:*

Street & Apt:#*

City:*

State:*

Zipcode:*

Telephone:* - -

Date of Birth:*

Gender:* Male Female

School:*

Grade:*

Does your child come from a Hispanic or Latino background?:* Yes No

Primary Race:*

Is your child multi-racial?:* Yes No

Home Environment:*

Health History Has your child ever been diagnosed with any of the following conditions? If yes, select the condition and please explain in detail.

Yes

Heart disease:

Diabetes:

High BP:

Seizure:

Asthama/Lung Condition:

Seizure:

Musculoskeletal condition or injury:

Allergy:

Other Serious Illness:

Please describe any medical conditions that may affect your child's participation in an exercise program:

Is your child taking any medications?:

Parent/Guardian Information Please answer the following questions about yourself:

First name:*

Last name:*

Relationship to child:*

Is your address same as that of your child?:* Yes No

Employment status:*

Work situation:*

Does your child qualify for free or reduced school lunch?:* Yes No

Emergency Contact Information

First name:*:

Last name:*:

Relationship to child:*

Phone:* - -

Healthcare Information

Primary source of healthcare:

Name of healthcare facility:

Primary Physician Information If you have a primary physician, please fill the details below:

Name:

Phone: - -

Fax: - -

* By checking this box I agree that all information above is accurate.
I hereby give permission to my healthcare provider to release any pertinent information to the GoKids Boston staff, and for GoKids staff to report back to him/her with all the information they collect.

If you have any concerns about releasing this information, please contact GoKids directly at 617-287-5437 and we will be happy to discuss the registration process with you.