Biggest Mover Application
Early Summer 2015
April 18 - June 27
Northwest Family YMCA
3840 North Monroe Ste 400
Tallahassee, FL 32303
(850) 536-9622
Parkway Family YMCA
2001 Apalachee Parkway
Tallahassee, FL 32301
(850) 877-6151
www.capitalregionymca.org
Program Information
Welcome to our Early Summer 2015 Biggest Mover Challenge! This letter will
outline the commitment needed to participate in the challenge so you can decide if
the program is right for you. This will be a commitment not only to yourself but to
your teammates as well. We want you to be successful and knowing what to expect
will aid you in your journey.
1. The challenge will officially kick-off Saturday, April 18, 2015. You will meet your
trainer and your teammates as well as other Biggest Mover contestants. At the
end of the kick off your trainer will weigh you in and take your measurements and
these will be your official starting numbers. Come dressed in comfortable workout
gear. You will receive your Biggest Mover Buff at the kickoff. You will also receive
some basic nutrition information from related questions you may have. This
information will help you get started on your journey. Once the program starts,
weekly weigh-ins will take place the second workout of each week; the weigh-in will
always take place before your workout begins. The team bulletin boards will be
updated every Monday. Only percentage lost will be on the board, not individual
weights. That will stay between you and your trainer and it will be up to you if you
want to share with your teammates.
2. The early registration fee (March 16 – March 29) for members is $200 and nonmembers $325 (pay in full ONLY). Regular registration will be from March 30 April 10. The cost is $225 for members and $350 for non-members if you pay
in full. If you choose the payment plan option, the cost is $250 for members,
$375 for non-members with a $100 deposit at the time of registration and the
balance will be paid in two equal installments on May 1, 2015 and June 1, 2015
by the Y automatically. Late registration will be from April 11 – 18, 2015. The
late registration fee for members is $325 and non-members $425, and this can
only be paid in full. Late registrants will not receive a Biggest Mover t-shirt.
3. Cancellations before Friday, April 10th will be assessed a $50 processing fee.
There will be no refunds issued for cancellations after Friday, April 17h.
4. Each team will have a minimum of three participants. The team roster is at the
discretion of the Biggest Mover competition coordinators. We will do our best
to accommodate your requested training session time and day based on our
trainers availability.
5. The person who is crowned the Biggest Mover will receive a prize package at the
end. The winner is determined by largest percentage of weight lost.
6. The team with the overall largest percentage weight lost will also receive a team
prize.
7. Points can also be earned by completing a weekly food journal as well as attending
group exercise classes. Total points will contribute to the individual amount of
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weight loss. You can earn 1 point each week by completing a food journal on
MyFitnessPal. This will be verified by your trainer. You can earn 1 point each week
by attending three group exercise classes. You will need to have the group
exercise instructor sign off on a card that your trainer will give you showing that
you attended the class, and then you will turn in the card to your trainer.
8. You and your teammates will meet two times per week with your personal trainer.
Team workouts are mandatory. Each participant will be given an “Excuse me from
training” pass that can be used once. After that the only excuse for missing
training is for a medical reason. If you have a vacation scheduled already, please let
your trainer know before the competition starts. Participants will not be able to
continue in the program if they miss workouts for other than the reasons listed
above and no refunds will be issued. You will be expected to schedule all other
activities around your two scheduled trainings per week. Please do not sign up for
the program if you are going to let other “things” get in the way. It really is a
choice. Take charge and do not let yourself or your team down.
9. In addition to your regularly scheduled workouts with your trainer, you will
receive additional weekly assignments to be completed on your own and in your
own free time. (Trainers may give you assigned workouts to do on your own.)
10. Your final training session will end the week of June 22, 2015. There will not
be a Week 10 weigh-in that week. The Biggest Mover finale will be on
Saturday, June 27, 2015 at the Parkway Family YMCA. Final weigh-ins will take
place at the finale and individual and team winners announced.
11. If you are ready to take the challenge, please fill out a health questionnaire and a
Biggest Mover Application, and turn them into the front desk. We will put the
teams together the week of April 13 and your trainer will contact you during that
week.
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REGISTRATION FORM
PLEASE FILL OUT THIS FORM COMPLETELY SO THAT WE CAN PLACE YOU ON THE
TEAM THAT FITS YOU BEST!!
Name: ______________________________________________
Address: _____________________________________________
Phone: ______________________________________________
Email: _______________________________________________
Preferred training location:
T-shirt Size: s
m
Parkway or Northwest (PLEASE CHOOSE ONE!!!)
l
xl
xxl
xxxl
Rank your top two available times:
_____ Monday/Wednesday Evening (5-7pm)
_____ Monday/Wednesday Late Afternoon (3-4pm)
_____ Monday/Wednesday Early Morning (5-6am)
_____ Monday/Wednesday Mid Morning (8-10am)
_____ Monday/Wednesday Lunch (noon)
_____ Tuesday/Thursday Evening (5-7pm)
_____ Tuesday/Thursday Late Afternoon (3-4pm)
_____ Tuesday/Thursday Early Morning (5-6am)
_____ Tuesday/Thursday Mid Morning (8-10am
_____ Tuesday/Thursday Lunch (noon)
Teammate(s) request: ___________________________________________________________________________
Trainer request: ________________________________________________________________________________
Physical Fitnessss Level
I have read the requirements needed to participate in the Biggest Mover
competition and am ready to make the full commitment.
Signature
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Payment Options
___ Early Registration (March 16 – March 30) – Pay in Full ONLY
Circle one: $200 (member)
$325 (non-member)
___ Registration (March 31 – April 10) – Pay in Full
Circle one: $225(member)
$350(non-member)
___ Registration (March 31 – April 10) – Payment Plan
Circle one: $250 (member)
$375 (non-member)
$100 deposit due. Balance will be paid in two equal installments on
May 1 and June 1, 2015.
(Fill out only if choosing payment plan option)
I hereby authorize the YMCA to initiate electronic fund entries to my
credit/debit card:
Card Type: ___ Visa ___ MasterCard ___ American Express ___ Discover
Name on Card: _________________________________________________________________________
Credit Card #: __________________________________________________________________________
Expiration Date: ___________/__________
___ Late Registration (April 11 - 18) – Pay in Full ONLY
Circle one: $325 (member)
$4025(non-member)
For office use only:
Amount Paid: $___________________
Method (circle one): Cash Check Credit/Debit Card
Date: _______/_______/2014
Staff Initials: _____________________
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Photo and Film Release Info:
The Capital Region Y will post Biggest Mover pictures on Facebook and the association website (individual weekly results are
posted on Facebook under the individual’s Biggest Mover picture) and other materials for motivational and marketing
purposes. Please sign the attached Photo Release Form to give us permission to share your picture. If you do not want your
picture on Facebook, please check off the following:
_______
I do not want my picture or any posted on Facebook but give you permission to use it on other marketing materials.
If you do not want your photo used for ANY marketing materials, please check off the following:
_______
form.
I do not want my picture used on any marketing material and DECLINE to sign the Capital Region Y PhotoRelease
I am 18 years of age or older and, if not, my Mother/Father/Legal Guardian has also signed below.
For my participation in activities to be conducted by the Capital Region YMCA, I hereby give my permission and consent, now
and for all time, to the Capital Region YMCA, the National Council of Young Men’s Christian Associations of the United States
of America (YMCA of the USA) and third parties collaborating with the Capital Region YMCA and/or YMCA of the USA to make,
reproduce, edit, broadcast or rebroadcast any video film, footage, sound track recordings and photo reproductions of me
and/or my narrative account of my experience at the Capital Region YMCA, for publication, display, sale or exhibition thereof in
promotions, advertising and legitimate business uses without any compensation to, and/or claim, by me. I may, or may not be,
identified in such reproductions; however, I shall not be stated by name to have endorsed any particular commercial products
or commercial services. I further agree to the following:
- Any video film, footage, sound track recordings, and photo reproductions of me and/or my narrative account of my experience
at the Capital Region YMCA, I authorize, according to this Release, shall belong to the Capital Region YMCA, YMCA of the USA
and third parties collaborating with the Capital Region YMCA and/or YMCA of the USA. Therefore, they will have full right of
disposition of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of
my experience with the Capital Region YMCA;
- Any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience
with the Capital Region YMCA will not be subject to any obligation of confidentiality and may be shared with and used by the
Capital Region YMCA, YMCA of the USA and third parties collaborating with the Capital Region YMCA and/or YMCA of the
USA;
- Capital Region YMCA, YMCA of the USA and third parties collaborating with the Capital Region YMCA and/or YMCA of the USA
shall not be liable for any use or disclosure to a third party of any video film, footage, sound track recordings and photo
reproductions of me and/or my narrative account of my experience at the Capital Region YMCA; and
- Capital Region YMCA, YMCA of the USA and third parties collaborating with the Capital Region YMCA and/or YMCA of the USA
shall exclusively own all known or later existing rights to worldwide and shall be entitled to the unrestricted use any video film,
footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience at the Capital
Region YMCA for any purpose without compensation to me.
I agree that my consent and this release are irrevocable. I hereby release and discharge the Capital Region YMCA, YMCA of the
USA and third parties collaborating with the Capital Region YMCA and/or YMCA of the USA from any and all claims in
connection with the uses and reproductions of any video film, footage, sound track recordings and photo reproductions of me
and/or my narrative account of my experience with the Capital Region YMCA as described herein.
Signature: _________________________________________________
Printed Name:
I am the Mother/Father/Legal Guardian of _
________
herein, I hereby consent to the foregoing on behalf of my minor child.
___________
Date: _____________________
(child’s name). For the consideration contained
Signature of Mother/Father/Legal Guardian: ________________________________________________________ Date: ____________________
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Health and Fitness Goals
This questionnaire will help us to understand your personal fitness goals. Your
responses will be treated in a confidential manner.
Today’s Date_____________________
Name_____________________________________
Please indicate your personal health and fitness-related goals:
___Lose Weight
___ Reduce Stress
___ Improve Aerobic Fitness
___Feel Better
___ Muscular Size
___ Muscular Strength
___ General Fitness
___ Look Better
___ Injury Rehab
___ Sports Specific
___Reduce Back Pain ___ Other________________
___ Improve Flexibility
___ Improve Diet
Please tell us more about your exercise patterns and goals:
What is your exercise history?
What health improvements do you need?
What health improvements do you anticipate?
What are your activity preferences?
What barriers do you anticipate, if any?
How will you know that you are succeeding?
What is your motivation level? High Medium Low
What is your confidence level? High Medium Low
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Activity History
How were you referred to this program?__________________________________
Why are you enrolling in this program?___________________________________
Do you have any injuries (bone or muscle) that may interfere with exercising?
YES______________ NO________________
If yes, briefly describe:
Do you smoke? Yes No
If yes, How much per day, what age did you start?
____________ a day __________________ age
Are you involved in a weight management program? Yes No
If yes, briefly describe:
List your present medications:
Are you interested in nutritional counseling? Yes No
ADDITIONAL NOTES:
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PERSONAL TRAINING PAR- Q AND INJURY RELEASE
Name
Part A
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Date
Has your doctor ever informed you of heart problems?
Do you frequently suffer from pains in your chest, if yes
Are they exacerbated by exercise?
Do you often feel faint or have spells of severe dizziness?
Has a doctor ever informed you your blood pressure was too high?
Has a doctor ever informed of any bone or joint problems that is
aggravated by exercise, or might get worse with exercise?
Are you over 65 years of age and unaccustomed to regular exercise?
Have you had any problems in the past while following an exercise
program?
Is there any physical reason not mentioned above as to why you
should not follow an exercise program even if you wanted to?
If you answered yes to any questions in Part A, you may need to get medical clearance from your
doctor before starting an exercise program.
Part B
Yes No
Do you have any knee problems?
Yes No
Do you have any lower back problems?
Yes No
Do you have any shoulder problems?
Yes No
Are you currently following and exercise program regularly?
Yes No
Do you follow a diet regimen?
List any medical conditions you have:____________________________________________________
Injury Release
I accept full responsibility for my use of any and all apparatus, appliance, facility, privilege, or service
owned and operated by the Capital Region YMCA, or while engaging in any activity arranged by the
Capital Region YMCA. I am participating in all exercise activity at my own risk, and shall not hold the
Capital Region YMCA or its’ employees responsible from any and all loss, claim, injury, damage, or
liability sustained or incurred by me resulting from any act or omission of an employee of the Capital
Region YMCA.
The Capital Region YMCA recommends that you have a physical examination and/or get the approval
of your doctor prior to beginning an exercise program. If you feel short of breath, dizzy, or feel pain
of any kind before, during, or after your exercise, please inform your personal trainer to prevent
further injury or hardship.
*NOTICE- All clients must notify their personal trainer 24 hours in advance to cancel a session, or
money for that session will be forfeited. Personal Trainer will wait 10 minutes after scheduled ½
hour personal training session and 15 minutes after scheduled 1 hour session until session is
canceled and money is forfeited.
Signature:________________________________________________________________________
Date:_________________________
Parent’s Signature:____________________________________________________________
Date:_________________________
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YMCA
PHYSICIAN’S APPROVAL
has completed a questionnaire which has
(Name of Participant)
highlighted the need for medical clearance. By completing this form, you are not
assuming any responsibility for our fitness program. If, however, you know of any
reason why the participant should not undertake a basic fitness orientation and
begin a regular workout program please indicate the reason below.
Thank you for your cooperation in this matter.
_________________________________________________has been examined by me
(Name of Participant)
and has my approval to participate in an exercise program with regards to any
recommendations or contraindications listed below.
________________________________________, M.D.
Physician’s Signature
___________________
Date
TYPE OF ACTIVITY
INTENSITY RESTRICTIONS (Y or N?)
Cardiovascular
_________________________________
Resistance Training
Flexibility
Other
____________________________________
____________________________________
____________________________________
PHYSICIAN’S RECOMMENDATIONS/CONTRAINDICATIONS
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