Youth Challenge Online Pre-Registration Form


How did you hear about the program (flyer, phone message, both)?
Participant's First Name
Participant's Last Name
Participant Phone Number
Participant Email Address
Date of Birth of Teen (mm/dd/yy)	- -
Child's Insurance Carrier -
Insurance Identification Number
Name of Primary Physician for the Child
Doctor's Phone Number
Did you get a letter from your Dr. to be in this program?	Yes No
Have you scheduled your Dr. Appointment?	Yes No
Name of Parent or Guardian
Participant Zip Code

You will be contacted about the next Youth Challenge session once your information is received. If you have any questions, please call us here at 215.545.4080. Do not forget to schedule an appointment with your child's doctor so that your child can bring the letter from your doctor stating that he/she can participate in the program. You will also need to bring your child's insurance card. Thank you for pre-registering your child(ren) and we look forward to seeing you soon!

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The Youth Challenge is a place to have fun, make friends and learn about fitness

Donita - Youth Challenge Participant 2009