Waco-McLennan County Public Health District Community ...



Waco-McLennan County Public Health District Community Diabetes Program | |

|APPLICATION FORM |

|Family Physical Activity Program- ZUMBA Fitness |

| |

|Please complete the registration form to the best of your ability. This program is intended for those at risk for or currently managing Type 2 |

|Diabetes. Your responses to the following questions are strictly confidential, but will be used to determine eligibility to participate in the |

|Family Physical Activity Zumba Fitness Program. |

|Name:       |

|Address:       |

|City:       |State:       |Zip Code:       |

|Phone Number: (   )     -      |E-mail Address:       |

|Race/Ethnicity | |Hispanic |White |Other | |

| |Black/Non-Hispanic | | | | |

|Gender: Male Female |Age:       |

| |

|HEALTH STATUS: Conditions you have been diagnosed with: (check all that apply) |

| |Amputation | |High Cholesterol |HEALTH INFORMATION: |

| |Diabetes | |Nerve Damage |Height (required) |      |

| |Dialysis | |Overweight |Weight (required) |      |

| |Eye Disease | |Pre-diabetes |BMI | |

| | | | | |(Administrative use) |

| |High Blood Pressure | |Blood Sugar or A1C |      |

| |Cholesterol |      |

| |Smoker |Yes No |

I wish to participate in the Family Physical Activity Zumba® Fitness Program for the purpose of personal fitness. I understand that I should have medical approval from my health care professional if I:

❖ Have any chronic health problems such as heart disease or diabetes

❖ Have pains in my heart and/or chest area

❖ Feel dizzy or have spells of severe dizziness

❖ Have a bone or joint condition, like arthritis, that might be made worse by an exercise program

❖ Have been told by a doctor that I have high blood pressure

❖ Have any physical conditions or problems that might require special attention in an exercise program

❖ Am a male over 45 or a female over 50 and not accustomed to vigorous exercise

I agree to accept full responsibility for any injuries I may sustain while participating in this program.

Signature       Date      

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