Fun For Cure, Inc.

Assessment Forms

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Initial Family Leisure History Assessment Form

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Name: *

Ages of Children:

Address:

E-mail address: *

Telephone/fax:

Past Fun and Rewarding Experiences as a Family Together

Past Fun and Rewarding Experiences for the Child(ren) Individually

Past Non Rewarding Experiences and Why?

Any Recreational Endeavors you have NOT had a chance to TRY, but want to?

Any Recreational Activity that your CHILD wishes to attend or participate in that he has NEVER had an opportunity?

Message: *

Any hopes and dreams for your family as a whole?

Hopes and Dreams for your CHILD(REN)?

Medical precautions or restrictions?

Allergies or Diet Restrictions?

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