Wellness Registration Form

The Bridge to Life
The Bridge to Life: Community Outreach & Wellness Program

Please complete this Pre-Registration Form to secure your spot in the Program.
Name *

First Name Last Name
Email
Contact Number *
Address *
City, State, Zip *
Where did you hear about the Community Wellness Program? *

Family or Friend Food Giveaway Social Media Flyer/ Advertisement Community Resource
If a community resource, what is the name of the organization?
In order for us to find out what your Goals are, please specify below what you are expecting from this program, and why?
I want to improve in the following areas: *

I want to lose overall weight I want to lose body fat I want to get fit and tone I want to eat healthier
What is your why? (Is there an event you are working towards? or do you want to improve your lifestyle?) Be specific!
Age
Height
Weight
Body Mass Index
To be calculated by Wellness Coordinator
Medical Conditions
Do you have any medical conditions or injuries that our Wellness Coordinators needs to be made aware of?
If yes, please discuss participation in exercise activity and dietary needs/restrictions with your doctor. List any information that our Wellness Team should know to help accommodate you.
Are you currently on any nutritional or meal replacement program which you intend to use in conjunction with this challenge? *

None USN Evox Weigh Less Herbalife Other
If other, please specify:
Dietary Analysis:

Please complete these questions in order for us to do a proper dietary analysis. Based on the information provided i will be able to supply you with appropriate information to help meet your goals. Please be totally honest even if it's KFC 5 times a week.
Eg: Junk Food: 3 times a week, KFC - Fully Loaded, Mc Donalds - Big Mc Meal Juice: 4 glasses a day
How many times per WEEK do you eat or drink the following:
Fruits
Number per week
Vegetables
Number per week
Whole Grains/Pasta/Rice
Number per week
Meat/Poultry/Fish
Number per week
Fruit Juice (Glasses)
Number per week
Water (Glasses)
Number per week
Junk Food (What do you order)
Restaurant (What do you order)
Water (Glasses per day)
Coffee and Tea (Glasses per day)
What do you normally eat:
Breakfast
Morning Snack
Lunch
Afternoon Snack
Dinner
Bedtime Snack

Do you..............

	Always	Sometimes	Never
Drink 8 Glasses of Water
Have 3 Meals a day

Thank you so much. Looking forward to seeing your amazing results!! NOW THAT THE HARD WORK IS DONE CLICK THE LINK BELOW TO REGISTER
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The Bridge to Life

The Bridge to Life: Community Outreach & Wellness Program

Dietary Analysis:

How many times per WEEK do you eat or drink the following:

What do you normally eat: