Child Fitness Readiness Survey
Please complete this survey to help us assess your child's readiness for physical activities and ensure their safety.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name and Relationship to Child
*
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does your child have any chronic illnesses, medical conditions, or injuries that may affect participation in physical activity?
*
No
Yes (please specify below)
If yes, please specify the medical conditions, injuries, or any relevant details.
Does your child have any allergies or take any medications regularly?
*
No
Yes (please specify below)
If yes, please list the allergies and/or medications.
How would you describe your child's current physical activity level?
*
Please Select
Very active
Moderately active
Occasionally active
Rarely active
Are there any physical activities your child should avoid?
Emergency Contact Name and Phone Number (if different from above)
Submit Survey
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