Geting Started in Our Program..

To sign up for Get With It and receive more information, please give us some information about yourself below. This information will be kept confidential and used only in conjunction with this program

Name

Address

Phone Number

Age

Please select the choice that best describes you:

(1 required)

	I've had a baby in the last 2 years			I am perimenopausal (going into the stages of menopause)
	I am menopausal			I am post-menopausal (no longer experiencing symptoms of menopause)
	None of the above/Other

Please describe your Nutrition and Physical Fitness Goals

Check all that apply

	Currently Overweight			Diabetes/pre- diabetic
	Heart Disease			Had a baby in the last two years
	Menopausal

In the space below, please elaborate on the boxes checked

How did you hear about GET WITH IT?

	Flyer from School			Referal from Health Care Provider
	Newspaper			Health Fair
	Poster			Friend/ Word of Mouth

10.

I would like to receive information about...

(1 required)

	Diabetes			Nutrition topics
	Weight Management			other
	Blood Pressure			Cholesterol

11.

What are your expectations of the GET WITH IT staff.

12.

What is the best way to get in touch with you?

(1 required)

	email			phone
	work phone			address

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