Healthy Lifestyle Improvements: Fit Kids FAMILY REGISTRATION

Healthy Lifestyle Improvements: Fit Kids
FAMILY REGISTRATION
Thank you for your interest in Fit Kids! The goal of Fit Kids is to guide families in
developing healthier eating habits, increasing physical activity and building selfesteem.
In order to attend a class, you will need to follow these steps:
1. Talk with the Fit Kids Program Coordinator to determine whether your family is a
good match for this program: Beth Passehl at 404-785-7236.
2. Complete the attached Registration Form
3. Obtain a signed “Permission to Participate” form from your doctor
4. Mail your registration and payment to the address listed
Please note that classes are limited to 12 families at each location!
Once you are registered, an individual meeting will be scheduled with your family to orient
you to our classes.
Thanks again for your interest in our Fit Kids program. We look forward to working with
you.
If you have any questions, please contact Beth Passehl at 404-785-7236 or
beth.passehl@choa.org.

Participant Name
Date of Birth
Participant Current Age
Parent Name(s)
Address
City, State, Zip, County
Home Phone
Work Phone
Email
Physician Name
Physician Address
Physician Phone
Healthy Lifestyle Improvements: Fit Kids
CLASS REGISTRATION FORM
Program Cost: $200.00
Please make checks payable to Children’s Healthcare of Atlanta.
For questions, or to determine whether your family is a good match for this
program, please contact:
Beth Passehl, MS
Fit Kids Program Coordinator
Phone: 404-785-7236
Email: beth.passehl@choa.org
Please return completed form to:
Beth Passehl, MS
Fit Kids Program Coordinator
1655 Tullie Circle
Atlanta, GA 30329
Fax: 404-785-7243

Healthy Lifestyle Improvements: Fit Kids
PERMISSION TO PARTICIPATE
(Please have your referring physician complete this form.)
I, ___________________________, agree that ________________________________
(Name of Physician) (Name of Participant)
is physically able to participate in the Healthy Lifestyle Improvements classes and would
recommend that the above named participant attend the classes.
__________________________________________
Physician’s Signature
__________________________________________
Date
Physician Name
Address
Phone
Email
Please return completed form to:
Beth Passehl, MS
Fit Kids Program Coordinator
1655 Tullie Circle
Atlanta, GA 30329
Fax: 404-785-7243

Healthy Lifestyle Improvements: Fit Kids
LAB REPORT FORM
(Complete with your child’s information.)
Child’s Name: ______________________ Age: _____ Date of Birth: ________ Sex: M F
Parent/Guardian Name: ___________________________________________________
Street Address: _________________________________________________________
City: ______________________________ State: _______ Zip Code: _______________
Phone: (Home) ________________ (Work) ________________ (Cell) _______________
Physician Name, Address & Phone
CURRENT ASSESSMENT (within past month):
Data Date of Measurement
Blood Pressure
Height
Weight
BMI
BMI %
LAB REPORT (within 3 months):
Total Cholesterol
LDL
HDL
Fasting Insulin
Fasting Glucose
Physician Signature: ____________________________________________________
Date: ________________________________________________________________
Please return completed form to:
Beth Passehl, MS
Fit Kids Program Coordinator
1655 Tullie Circle
Atlanta, GA 30329
Fax: 404-785-7243
Data Date of Measurement