Healthy Lifestyle Improvements: Fit Kids FAMILY REGISTRATION

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