District Home - Health and Fitness Survey for Parents

Health and Fitness Survey for Parents

Name (Optional)

First Name

M.

Last Name

Email Address (Optional)

Phone Number (Optional)

- -

(XXX)-XXX-XXXX

* Do you live in Pearl?

Yes
No

* Do you have children attending school in the Pearl Public School District?

Yes
No

* What schools do your students attend? Check all that apply.

Pearl Lower Elementary (Kindergarten - 1st Grade)
Northside Elementary (2nd Grade - 3rd Grade)
Pearl Upper Elementary (4th Grade - 5th Grade)
Pearl Junior High School (6th Grade - 8th Grade)
Pearl High School (9th Grade - 12th Grade)

* How would you classify the fitness level of your students?

fit
somewhat fit
not fit at all

* Do your students excercise regularly?

Yes
No

* Do your students eat healthy meals?

Yes
No

* How would you classify your fitness level?

fit
somewhat fit
not fit at all

* How often do you excercise?

everyday
5 times per week
3 times per week
never

* Are you a member of a health club or gym?

Yes
No

Are you interested in starting a regular exercise program?

Yes
No

* What type of excercise would you be interested in doing? Check all that apply.

aerobics class
yoga class
weight lifting
running/walking

* Are you on a special diet as prescribed or recommended by a physician?

Yes
No

* Are you interested in learning more about healthy eating?

Yes
No

* Are you interested in attending a school-sponsored health program on exercise and/or healthy eating?

Yes
No

* Would you be interested in becoming a member of a school Health/Wellness Council? If yes, then please provide optional contact information located at the top of this form.

Yes
No

What would you like to see the school district do at school to improve student health? Type your answer in the space provided.