Healthy Weight And Your Child
A Healthy Eating and Active Living Program brought to you by the YMCA
Are you a Healthcare Provider wishing to refer a patient?
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Yes
No
Health Care Provider statement:
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I know of no reason why the child may not participate
I know the child can participate, but I urge caution (explain below)
The child should not engage in specific activities (explain below)
I recommend the child NOT participate
If you urge caution or recommend the child to not engage in specific activities, please list them below:
Name of Health Care Practice (if not listed, fill out below in the blank)
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Please Select
Carolina Pines
CareSouth
Lamar Medical
Morphus Medical Group
Health Care Provider Name
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First Name
Last Name
Name of Health Care Practice (if not in the drop down list)
Health Care Provider Signature
Optional: Signed Medical Clearance
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ADULT INFORMATION
Adult Name
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First Name
Last Name
Relationship to Child
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Phone Number:
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Email
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Preferred Contact Method:
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Email
Mobile - Call
Mobile - Text
Home Phone
PARTICIPANT/CHILD DETAILS
Child Name
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Child's First Name
Child's Last Name
Child's Nickname/Preferred:
Child's Date of Birth
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Month
-
Day
Year
Date
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