Referral To Act Program From A Healthcare Provider printable pdf download

Referral To Act Program From A Healthcare Provider

ACT! ACTIVELY CHANGING TOGETHER

EATING WELL. PLAYING MORE.

Ready for a healthy change? Looking for ways to help your child eat well and be more active?

It’s time to ACT! In partnership with Seattle Children’s Hospital, the YMCA offers ACT! for youth ages 8-14.

Program highlights:

 One 90-minute group session per week for 12 weeks

 Y family membership to use between weekly sessions

 A nutritionist and physical activity coach lead each session

 Parents join the program together with their kids

 Energizing games, activities and light meals

 Offered twice a year (Fall and Winter)

 Fees range from $25 - $165 based on ability to pay

READY TO ACT! NOW?

A healthcare provider referral is required to enroll (may be a doctor, registered

nurse, registered dietitian or any licensed healthcare provider) and youth must

have a body mass index (BMI) ≥85

percentile. You and your child’s healthcare

provider can complete this form and fax it to your preferred Y branch. Y staff

will then contact you to discuss participating and help you enroll.

Parent completes the following:

Provider completes the following:

I would like to receive more information about ACT!

I confirm this child/teen is eligible for ACT! with age

8-14 years and BMI ≥ 85

percentile for age

I am ready to reserve a spot in the ACT! program

I confirm this child is physically and emotionally able

Child Age_________ Child Sex

Male

Female

to participate in group physical activity

Child/Teen name

Child/Teen height (cm)

Weight (kg)

Age

Parent/Guardian name

Provider name

Address

Signature

Preferred contact phone

Date

Email address

Clinic

How did you find out about ACT!?

Email or Fax

Preferred Y branch (see list on back)

Please fill-in health information about the child/teen that may

See reverse side of where to send completed form.

impact physical activity and/or nutrition in the program

(allergies, illnesses, etc.):

Everyone is welcome. Financial assistance is available. The YMCA of Greater Seattle

strengthens communities in King and south Snohomish counties through youth

development, healthy living and social responsibility.

Referral To Act Program From A Healthcare Provider

Related Articles

Related forms

Related Categories