Wufoo
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.
Name
*
First
Last
Choose the weekly class you will attend:
*
Tuesdays Noon - 1 pm, Mining & Minerals Building
Tuesdays 5:15 - 6:15 pm, Nursing Building
Thursdays 11 am - Noon, Biological Pharmaceutical Complex
ONLINE CLASS IS FULL- Register for waiting list
Choose your desired start week:
*
February 16, 17, or 18
March 23, 24, or 25
April 27, 28, or 29
Have you attended Weight Loss Matters in the past?
*
No
Yes
Email
*
Work Phone
###
-
###
-
####
Home Phone (if NOT a UK employee)
###
-
###
-
####
Gender
*
Female
Male
Age
*
Weight
*
Height (feet)
*
4
5
6
Height (inches)
*
0
1
2
3
4
5
6
7
8
9
10
11
12
10 week weight loss goal (in pounds). Be realistic!
*
Are you physically active?
*
No
Yes
If you are physically active, please answer these three questions:
Number of days per week you are active:
1
2
3
4
5
6
7
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:
*
UK employee
Spouse/sponsored depdendent
Retiree
BCTC Cooper Campus Employee
If spouse or sponsored dependent, UK employee's name:
How did you hear about Weight Loss Matters?
*
Web site
Flyer mailed to department
Staff Listserv
Healthtrac
In the Loop
Wellness Advocate
New Employee Orientation
Spouse
Co-worker or friend
Other
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.
*
I agree
Do Not Fill This Out
