Registration Form - Weight Loss Matters
Complete this form to register for the Weight Loss Matters program.
NOTE: The registration fee for new participants is $50. You will receive a confirmation email with instructions for payment when you submit your registration form.
Person ID (if UK employee):
Choose your preferred class and start date from the list below:
In-person, Tues Noon-1 pm, start January 14
In-person, Tues 5:15-6:15 pm, start January 14
Online, Wed Noon-1 pm, start January 15
Do you want to join the Biggest Blue Loser competition that occurs from January 13 to March 25, 2015?
YES! Sign me up for the Biggest Blue Loser competition!
Have you attended 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:
If spouse or sponsored dependent, UK employee's name:
How did you hear about Weight Loss Matters?
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 Weight Loss Matters Agreement:
As a new participant in the Weight Loss Matters 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 Weight Loss Matters program. I am aware that failing to provide the Weight Loss Matters staff with adequate information on any and all medical conditions will impair their ability to advise me properly.
Do Not Fill This Out