Kid Fit Referral form


Kid fit is a 12 week program that meets every Tuesday and Thursday at 4:45pm-6:15pm.

This program is taught in conjunction with Island Health Fitness.
It provides a supportive environment in which overweight kids
(ages 8-17) can improve their exercise and eating patterns.

To sign up call the Cayuga Center for Healthy Living program
(607) 252-3590

Please print and bring this form with you.

Name:

____________________________________

Address:

____________________________________

Guardian's Name:

____________________________________

Phone Number:

____________________________________

Referring Physician:

____________________________________