Healthy Lifestyle Improvements: Fit Kids FAMILY REGISTRATION

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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
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Healthy Lifestyle Improvements: Fit Kids FAMILY REGISTRATION

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