UMass Boston / GoKids / Enrollment Form

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GoKids Participant Registration

ABOUT PARTICIPANT:

Please answer the following questions about your child.

First Name:
Last Name:
Address:
City:
State:
Zip:
Date of Birth:	(mm/dd/yyyy)
Parent's Phone:
Gender:	Female Male
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? Yes No
Who resides in the household with your child?
Both Parents Single Mother Single Father Grandparent(s) Other

HEALTH HISTORY:

Heart Disease:	Yes No	Explanation:
Diabetes/High Blood Sugar:	Yes No	Explanation:
High Blood Pressure:	Yes No	Explanation:
Seizure:	Yes No	Explanation:
Asthma or Other Lung Condition:	Yes No	Explanation:
Cancer:	Yes No	Explanation:
Musculoskeletal Condition or Injury:	Yes No	Explanation:
Other Serious Illness:	Yes No	Explanation:
Allergy:	Yes No	Explanation:

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:
(For Child)

Doctor's Office

Walk-In Clinic

Hospital

Community Health Center

Name of Healthcare Facility:
If your child has a primary physician, please fill in the details below:
First Name:
Last Name:
Phone:
Fax:

ABOUT PARENT/GUARDIAN:

Please answer the following questions about yourself.

First Name:
Last Name:
Email Address:
Relationship to Child:
Address:	Use previously filled Enter different address
Street & Apt #:
City:
State:
Zip Code:
Primary Phone:
	Home Work Cell
Secondary Phone:
	Home Work Cell
What is your employment status?
	Employed (35 hours or more per week) Employed (less than 35 hours per week) Student Not employed Other
What is your highest level of education?
	Some High School High School Diploma/GED Some College 2-year College Degree 4-year College Degree or higher Other
Does your child qualify for free or reduced-price school lunch program?
	Yes No

EMERGENCY CONTACT:

(In addition to Parent/Guardian above)