Download Waco-McLennan County Public Health District Community Diabetes

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:
Phone Number: (
)
State:
E-mail Address:
-
Black/NonRace/Ethnicity
Hispanic
Gender:
Male Female
Hispanic
Age:
White
Zip Code:
Other
HEALTH STATUS: Conditions you have been diagnosed with: (check all that apply)
Amputation
High Cholesterol HEALTH INFORMATION:
Height
Diabetes
Nerve Damage
(required)
Weight
Dialysis
Overweight
(required)
Eye Disease
Pre-diabetes
BMI
(Administrative use)
Blood Sugar
High Blood Pressure
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
Please return the completed application to [email protected]
or via fax at (254) 750-5405.