Program Application Home Programs Program Application Applicant InformationSchool or Organization Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County School/Organization Phone NumberSchool/Organization Website School District Network/Affiliation Contact Name* Contact Title/Role Contact Direct Phone*Contact Email* Who will implement the Fit Kids program at your school site? (Check all that apply.) PE Teacher Athletic Director Classroom Teachers Volunteer Other How did you hear about Fit Kids? Currently using Fit Kids Program My school/organization used Fit Kids last school year Internet Search Referral If Referral, who can we thank? Program Request Options (Check all that apply)* Purchase a 1 year Program Membership for $3,500; includes curriculum and equipment. Program may be converted to an Online Membership upon renewal. Purchase a 1 year Online Membership for $1,000; curriculum only. Enlist Fit Kids’ guidance to help fundraise the $3,500 fee. Enlist Fit Kids’ guidance to help fundraise the $1,000 fee. Join Fit Kids’ wait list until a free program becomes available. School/Organization Info & DemographicsPlease list the percentage of students at your site for each category below.White or CaucasianHispanic or LatinoBlack or African AmericanNative American or Alaskan NativeAsian or Pacific IslanderOtherPercentages should add up to 100%.What percentage of the children in your school/organization qualify for free-or-reduced lunch? Please select all the grade levels your school/organizations serves. TK K 1st 2nd 3rd 4th 5th 6th 7th 8th Please select all the grade levels that will participate in Fit Kids. TK K 1st 2nd 3rd 4th 5th 6th 7th 8th List the number of students that will participate in Fit Kids. Please use whole numbers. Short Answer Questions1. When will your school/organization use Fit Kids? (Check all that apply.) During the school day After the school day Summer 2. Does your site have a PE program? Yes No 3. Does your site have an after school sports program? Yes No 4. Do your students participate in any structured physical fitness activities after school? Yes No If Yes, explain:5. Please explain the need for the Fit Kids program for your school/organization.6. Please tell us how the Fit Kids Program will fit into your existing health and fitness plans.Disclaimer and SignatureConsent* I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application may result in ineligibility to receive the program.Printed Name* Title/Role* Date* MM slash DD slash YYYY
