Center for Healthy Children Application

NEA Baptist Charitable Foundation Center for Healthy Children will provide (free of charge) nutrition education, diet and exercise programs for children who are overweight. The parents of these children will also be expected to attend nutrition classes along with their child, and be committed to the program for a period of 12 weeks, 3 days per week. You will receive a letter in the mail letting you know if your child(ren) qualify.

Questions? Call us at (870) 936-7960 or email erica.huffstetler@bmhcc.org

Program Application

Child's Name*
Age*
Birth Date*
Height*
Weight*
School*
Grade*
T-shirt Size*
Applicant Name*
Relationship to Child*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Family Physician*
List current health problems and/or allergies:*
List current activities/sports:*
Family history (heart disease, diabetes, etc.):*
Mother's Name*
Age*
Height*
Weight*
Father's Name*
Age*
Height*
Weight*
Briefly describe why you wish to enroll your child in the Center for Healthy Children:*