Women In Motion Application Form

 

WIM adheres to HIPAA guidelines, and will keep all personal and medical information confidential. The Program Director alone has access to this information.

Your Name (required)

Your Email (required)

Birthdate (required)

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Phone Number (required)

Type (required)

Your Address (required)

City (required)

State (required)

Zip Code (required)

Returning WIM Participant? (required)

If yes, what year?

The Women in Motion program is designed to serve women with a specific set of high-risk health factors. In order to qualify for WIM, you must have at least one of the following: BMI over 30, blood pressure over 140/90, Total Cholesterol over 240, or Hemoglobin A1c over 6.5%. You will be required to provide clinical results from a physician for verification before the WIM program start date. If you are unsure of the following information, please guess. You can verify numbers with your physician when you get consent to participate in WIM and report them to Rachel for any necessary changes (rslivewll@gmail.com).

Height (required)

Feet Inches

Weight (required)

Blood Pressure (required)

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Total Cholesterol (required)

A1c (required)

%

Please attach your Physician Consent Form, if available. It is not required for the application, but you will need to provide it before participation in Women in Motion begins. You may also email the completed form to womeninmotion.ogden@gmail.com

Which event would you like to register for? (required)


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