ARE YOU INTERESTED?
			Either mail your completed form to 305 Freer Hall 906 S Goodwin Ave, M/C 052, Urbana, IL 61801
O			or e-mail your completed form to jbensken@illinois.edu  

											__________			
Child’s Last Name,  First Name					Grade (Fall 2016)	M/F		Date of Birth	School (Fall 2016)

															
Street address								Town			Zip Code

													
Guardian 1   Last Name, First Name					Guardian 1 E-mail address

														
Guardian 1 Home Phone Number		Guardian 1 Cell Phone Number 	Text? (Y/N)	Guardian 1 Work Number

													
Guardian 2 Last Name, First Name					Guardian 2 E-mail address

														
Guardian 2 Home Phone Number		Guardian 2 Cell Phone Number 	Text? (Y/N)	Guardian 2 Work Number

What is the preferred method for us to contact you?  For example, “Guardian 1 E-mail” or “Text Guardian 2”
1.	 								
2.	 								

QUESTIONS TO ANSWER TO HELP US PLACE YOUR CHILD --  THE APPROPRIATE BOX

YES	 NO	Is your child between the ages of 8 and 9? (We are only recruiting for children in this age window)

YES	 NO	Is your child able to participate in exercise and physical activity?	

YES	 NO	Is your child going to live in the Champaign/Urbana area between August 2016 and May 2017?

YES	 NO	Is your child available most days afterschool to participate in our program?

YES	 NO	Is your child involved in other afterschool activities?  If so, what are they?

YES	 NO	Would your child require transportation to the afterschool program? 
		(buses offered from Urbana schools and some Champaign schools)

YES	 NO	Would you be available to pick your child between 5 and 5:30 pm from the U of I campus?  

How did you hear about FITKids?_____________________________________________________________

What is the best day/time to call you with more information?_____________________________________