Registration Form - EatWell Weight Loss
Complete this form to register for the EatWell weight loss program.
NOTE: The cost of EatWell Weight Loss is $50 for a lifetime membership. Instructions for payment will be included in your confirmation email. Returning participants do not need to submit any payment.
Person ID (if UK employee):
Date of Birth (MM-DD-YY)
Choose your preferred class and start date from the list below:
In-person, Tues Noon-1 pm, start Jan 12
In-person, Tues 5:15-6:15 pm, start Jan 12
Online, Wed Noon-1 pm, start Jan 13
In-person, Tues Noon-1 pm, start Feb 16
In-person, Tues 5:15-6:15 pm, start Feb 16
Online, Wed Noon-1 pm, start Feb 17
Have you attended EatWell Weight Loss (formerly known as Weight Loss Matters) in the past?
ONLINE CLASS ONLY: Please provide your preferred mailing address (STREET ADDRESS).
Please set a range for your 10-week weight loss goal (examples: 0-5 lbs, 5-10 lbs, etc.) Remember to be realistic!
Are you physically active?
If you are physically active, please answer these three questions:
Number of days per week you are active:
Number of minutes per day you are active:
Type of activity (walking, biking, etc.)
Please list your current medical conditions:
Please list all medications and supplements (prescription and non-prescription):
Choose your status:
Eastern State employee
ARMS (formerly CKMS) employee
If spouse or sponsored dependent, UK employee's name:
How did you hear about EatWell Weight Loss?
Co-worker or friend**
New Employee Orientation
In the Loop Newsletter
UK Health & Wellness website
UK LiveWell Check In Event
Wellness Specialist, contacted regarding provider referral
**If applicable, please tell us who referred you so we can thank them!
Please read and accept the EatWell Weight Loss Agreement:
As a new participant in the EatWell Weight Loss program, I have read and understand the program description, which includes, but is not limited to, the following.
What to Expect:
- A weight loss program that teaches you how to eat, rather than how to diet
- The expertise of registered dietitians
- Group support for your weight loss goals
- Weekly weigh-ins and educational seminars
- A meal pattern calculated just for you (includes a daily calorie level and general outline for how many foods to eat from each food group)
What Not to Expect:
- A quick fix
- A rigid meal plan – you will have the flexibility to decide what specific foods to eat each day
- Daily menus that take the “guesswork” out of losing weight – you will decide when and what to eat throughout the day and adapt the meal pattern to your lifestyle
- “Off-limits” foods – this program allows you to “fit all foods”
I agree to carefully follow the meal plan and dietary guidelines set forth in the EatWell Weight Loss program. I am aware that failing to provide the EatWell Weight Loss staff with adequate information on any and all medical conditions will impair their ability to advise me properly.
Do Not Fill This Out