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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