refer a child

Physician Referral
As a physician or nurse, you see firsthand the effects of unhealthy weight on a child’s overall health status. We would like to work with you in ensuring every family in our community has access to a program to support child health.

If you know of a child and family that can benefit from a FREE 8-week comprehensive program designed to introduce children to healthy lifestyles, please refer them to the ProActive Kids Foundation.

Our most dedicated participants are those who have been referred by their doctors!

The physician referral form that allows you to refer families to the PAK program. Feel free to print these flyers and distribute in your offices – Download the Flyer and Physician Referral Form.. We can also send posters if you email us at

The families are responsible for getting this form signed and delivered to PAK as their first step in advancement in the program. Children must have a signed physician referral form to participate in the program.

Please note:
  • The referral form is on the back of the general flyer.
  • Doctors must sign the form and give it to the patient. The patient is responsible for bringing it to the program.
  • Doctors CANNOT enroll a child or fax in form. They must simply direct the family to ProActive Kids website or phone number to enroll the child.