UMass Boston / GoKids / Student Registration

How to Join

UMass Students Registration Form

Student Information Please answer the following questions about yourself:

First name:*

Last name:*

Street & Apt #:*

City:*

State:*

Zipcode:*

Telephone:* - -

Date of Birth:*

Gender:* Male Female

Are you from a Hispanic or Latino background?:* Yes No

Primary Race:*

Are you multi-racial?:* Yes No

Health History Have you ever been diagnosed with any of the following conditions? If yes, 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 participation in an exercise program:

Are you taking any medications?:

Academic Information

What college at UMB are you a part of?*

What is your major?:*

If you are an EHS student, what is your focus?*

What is your involvement at GoKids?*

If you are working at GoKids as a part of class, which class?*

Emergency Contact Information

First name:*

Last name:*

Relationship to you:*

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.