NEW YEAR NEW YOU! Register By: Jan. 12th Program Run: Jan. 12th - Apr. 2nd Member: $20.15 / Non-Member $120.15 (includes 12 week Y membership) Bring in 2015 with this 12 week jump start! Sign your declaration of resolution to lose weight, eat healthier, start exercising and find new ways to live a healthier lifestyle! The program will include: • Before/After Health Assessment - includes blood pressure, body fat/BMI, flexibility, measurements and weight. (all information is kept confidential) • Guidance from Hy-vee Dietitian: Heather Ware * 6 - Nutrition & Wellness Sessions * Unlimited “Ask the Dietitian” Access * Analysis of your daily nutrition * “Nutrition Tips” E-newsletter • 2 - 30 min Personal Training Sessions with your choice of one of our 10 nationally certified Personal Trainers. • Weekly weigh-ins • 10% OFF AT SUBWAY ACROSS FROM THE Y! PLUS prizes for each category for the most: 0.15 2 $ Y ONL • Pounds lost • Body fat % lost • Inches lost • Participation during the 12 weeks All of this for the New Years Blow out price of $20.15 for member, and $120.15 for a non-member! You’ve got nothing but weight to lose and nothing but life to gain! For more information contact Kathy at (641) 684-6571 ext. 26 A NEW YEAR A NEW YOU! REGISTRATION FORM (Must be 16 years of age or older to participate) First Name:___________________________________ Age:________ Gender:_____________ Last Name:____________________________________ Date:____________________ Phone:__________________________ E-mail:_____________________________________________ Address:___________________________________________ City:__________________________ State:___________ Zip:________________ OFFICE USE ONLY FEES: Member: $20.15 Non-Member: $120.15 (includes 12 week Y membership) Paid:_____________ Packet Given:___________ Date:_______________ Staff Initials:________ PARTICIPATION AGREEMENT (This must be signed by the participant) I am entering the Ottumwa YMCA a new year, a new you program. I understand the risks involved in this type of event and I agree I am taking part in this event at my own risk. By signing this form, I release the Ottumwa YMCA, City of Ottumwa, Ottumwa Hy-vee Stores, sponsors, organizers, volunteers and officials from any liability including claims for personal injury, death, and other damages that occur during, because of, or in travel related to my participation. Participant Signature Date Statistics: Height Weight Body Composition BMI Blood Pressure Flexibility Measurements Right Bicep Left Bicep Right Thigh Left Thigh Hip Waist STAFF DATE Parent/Guardian Signature Before After Date Total Shoes: ON OFF Par Q Form Does participant require medical clearance? Yes No Medical Clearance Received: Date:____________ GRAND TOTAL