How Active Is Your Child?

Aloha! Please respond to each question as best as you can for each child. Mahalo (Thank you).

Parent's First Name:
Parent's Last Name:
Email Address:
Address:
City:
State:	Select One... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Other-Not Shown
Country:
Zip/Postal Code:
Phone Number:
Fax Number:
Child's Name:
Child's Age:
Child's Name:
Child's Age:
Child's Name:
Child's Age:
Child's Name:
Child's Age:
Child's Name:
Child's Age:
Child's Name:
Child's Age:
How many minutes of physical education does your child get each week?	Select... 0 minutes 1-60 minutes 60-90 minutes 90+ Other
Does your child/children have any special needs?	Select... none Asthma Allergies Physical Disability Learning Disability Behavioral Diabetes Medications Other
Does your child participate in a community-based fitness activity?	Select One... Yes No
How many hours a week does your child participate in one or more of the following:	Select One... 0 1-3 4-7 7+
Aerobic dance	Badminton
Basketball	Baseball
Bicycling	Calisthenics
Diving	Football
Golf	Gymnastics
Hiking/backpacking	Horseback riding
Jumping rope	Martial arts
Paddling	Rodeo
Roller hockey	Running
Skating	Skiing
Soccer	Softball
Swimming	Table tennis
Tennis	Track and field
Volleyball	Walking
Weight lifting	Wrestling
How many hours a day does your child watch TV, play video games, or is on the computer?	Select One... less than 1 1-2 2-3 3+
Do you think your child is fit?	Select One... Yes No
Does your child think he or she is fit?	Select One... Yes No
Additional Comments: