Healthy Weight And Your Child
A Healthy Eating and Active Living Program brought to you by the YMCA
ABOUT YOU - ADULT DETAILS
Name
*
First Name
Last Name
Relationship to Child
*
Phone Number:
*
Email
*
Preferred Contact Method:
*
Email
Mobile - Call
Mobile - Text
Home Phone
How did you hear about the program?
*
Current/Former Program Participant
Doctor/Other Health Care Professional
Employer
Family/Friend/Word of Mouth
Health Insurance Company
Media/Marketing
Screening Event/Health Fair
Y Staff Member/Volunteer
Other
Are you and your family members of the Y?
*
Yes
No
Employer Name
PARTICIPANT/CHILD DETAILS
Child Name
*
Child's First Name
Child's Last Name
Child's Nickname/Preferred:
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Sex
*
Male
Female
(Self-Reported) Height in inches for Child(ex: 5 feet X 12 = 60 inches)
*
(Self-Reported) Weight for Child (lbs)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your Child of Hispanic, Latino (a), or Spanish Origin?
*
Yes
No
Prefer not to answer
What is your child's race? (Check all that apply)
*
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
A race not listed here
Prefer not to answer
Is your child eligible for free or reduced school lunch?
*
Yes
No
IN THE PAST 12 MONTHS, did anyone in this household receive Food Stamps or a Food Stamp benefit card? Include government benefits from the Supplemental Nutrition Assistance Program (SNAP - Do NOT include WIC or the National School Lunch Program).
*
Yes
No
Submit
THANK YOU!
All enrollees please hit the submit button. The next page is for YMCA Staff only.
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BASELINE MEASUREMENTS
CHILD MEASUREMENTS
Date of Measurement:
-
Month
-
Day
Year
Date
Measurements taken by:
Please Select
Parent
Physician
Y Staff
Height (ft/in)
Weight (lbs)
Height (ft/in)
BMI ≥ 95 percentile?
Yes
No
ADULT MEASUREMENTS
Date of Measurement:
-
Month
-
Day
Year
Date
Adult's Name
First Name
Last Name
Measurements taken by:
Height (ft/in)
Weight (lbs)
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YMCA Staff Only:
Participant Contact Log
*
Participant is
Contacted
Waiting on Medical Clearance
Waitlisted
Enrolled
Withdrew
Completed
Class / Cohort Name
Class Location
Cohort Leaders:
First & Last Name
First & Last Name
Cohort Start Date
Cohort Finish Date
Program Fee Paid/Financial Assistance:
Below forms are signed and on file:
Medical Clearance Form
Consent and Release from Liability
Authorization for Use and Disclosure of Health Information
Authorizations for Release of Information to Health Care Provider
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Attendance and Family Huddle Tracker
Ensure to complete entire table. Measurements are to be collected at Session 1 and Session 25
Date of Session
Attended?
Make up Session Conducted
Completed Family Huddle Journal?
Successes
Challenges
Ht
Wt
Ht
Session 1
Yes
No
Session 2
Yes
No
Session 3
Yes
No
Session 4
Yes
No
Session 5
Yes
No
Session 6
Yes
No
Session 7
Yes
No
Session 8
Yes
No
Session 9
Yes
No
Session 10
Yes
No
Session 11
Yes
No
Session 12
Yes
No
Session 13
Yes
No
Session 14
Yes
No
Session 15
Yes
No
Session 16
Yes
No
Session 17
Yes
No
Session 18
Yes
No
Session 19
Yes
No
Session 20
Yes
No
Session 21
Yes
No
Session 22
Yes
No
Session 23
Yes
No
Session 24
Yes
No
Session 25
Yes
No
Success Notes
Challenges Notes
Preview PDF
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