Healthy Futures West Louisville Enrollment
This program is provided in partnership with the Louisville Urban League's Healthier Path Forward to combat childhood obesity. The program will improve the health and wellness of children through nutrition education, access to FREE healthy food, health screenings, physical activity, and family engagement. Program is for children ages 5–17. Please complete the consent form to enroll in the program.
Student Information
Child Full Name
*
First Name
Middle Name
Last Name
Child Height
*
In inches
Child Weight
*
In pounds
Child Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home Street Address
*
Home City, State, ZIP
*
Parent / Guardian Information
Parent / Guardian Full Name
*
First Name
Middle Name
Last Name
Preferred Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Email Address
*
example@example.com
Preferred Contact Method
Phone
Text
Email
Relationship to Child
*
Please Select
Parent
Guardian
Grandparent
Aunt/Uncle
Sibling
Family Friend
Other
Consent and Authorization
Consent for Program Participation
*
I consent to my child participating in the Healthier Futures West Louisville program.
Health Screenings Acknowledgment
*
I understand screenings and services are optional and will be explained individually
Parent / Guardian Printed Name
*
First Name
Last Name
Parent / Guardian Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Enrollment
Submit Enrollment
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