WENATCHEE RACQUET & ATHLETIC CLUB FALL 2022 KICK START QUESTIONNAIRE

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Please complete the following to register for KS FALL 2022, SEPTEMBER 16-OCTOBER 13.

Name: *

Phone number: *

Email: *

What is your MAIN GOAL by participating in the KICK START? *

How many meals/snacks do you currently consume on average per day? *

How often do you do cardiovascular exercise per week? *

For your cardiovascular exercise, what is the normal duration? *

How often do you do strength train per week? *

For your strength training, what is the normal duration? *

Do you do any other forms of exercise? *

Yes

Type the forms of exercise on the "other line" below:

Other:

Are you currently under the care of a Physician? *

Yes

Type what you are you currently under the care of a physician for on "other" line below:

Other:

Are you currently taking any medications? *

Yes

Type what you are you currently taking medications for and how long you have been taking them for on "other" line below:

Other:

Have you been diagnosed as Diabetic? *

Pre-diabetic

Type I

Type II

Other:

If diagnosed as Diabetic, what medications and frequency do you take:

Have you had any form of Bariatric Surgery? *

Yes

If you had Bariatric Surgery, what type did you have and when was the surgery performed?

If you had Bariatric Surgery, approximately how many ounces of food can you ingest per sitting?

Have you ever dealt with an eating disorder that we should be made aware of?

Yes

If yes, please explain on line below.

Other:

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Are you currently lactating?

Yes

If yes - how many times per day?

Other:

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Are you a Vegan?

Yes

Clear selection

Do you have Celiac Disease or a high Gluten Sensitivity?

Yes

Clear selection

Is there anything you'd like to disclose that we need to know to support you to be successful during the 28-Day program that has not been identified above?

I have disclosed all necessary information that the Balanced Habits KICK START Team needs to know about me. I understand what is expected of me during this 28-Day program and commit to the suggestions and guidelines. I will attend the weekly journal review, follow the journal requirements, do the suggested amount of exercise. I will read the emails coming from my Food Coach. I promise to not expect perfection, but I do expect improvement due to my efforts and understand that the Kick Start fee is non-refundable. Type your name below to indicate that you agree with these statements.

REGISTRATION FEE: $249 M / $299 NM

I am a WRAC member and authorize the fee charge on my house account.

I am a WRAC member but please contact me for an alternate form of payment.

I am not a WRAC member, please contact me for payment information

Other:

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Non WRAC members, please complete these additional questions.

Birthdate: *

YYYY

Mailing Address: *

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