Healthy Charleston Challenge Application January 2010
PLEASE PRINT-

Name: ______________________________________    Male / Female ________

Address: ____________________________________________
              
            _____________________________________________
               
Phone:______________ Email (We must be able to read this) _______________

Are you a memeber of the MUSC Wellness Center? No___ Yes ____ (number______)

Age: ___    Height ______      Weight _______ Do you smoke? ______   

Medical Concerns:    * Please circle ALL that apply to you.
Diabetes,  Heart Disease,  High Blood Pressure, High Cholesterol, Recent surgery, Thyroid Condition, Hernia, Asthma, Arthritis. 
Other Health Concerns (use back)
Circle if you have pain (other than pain from arthritis) in the following areas:  
Back Pain,   Neck Pain,   Knee Pain,   Hip Pain       
How many pounds do you need to lose? (must be over 20 lbs.) _________
Has a Doctor ever told you not to exercise? ____________________
If so, why? __________________________________________(Use Back)

What time of day would be best for your team workouts? (please circle)
6:00am   9:00am   12:00 noon   5:00pm   5:30pm   6:00   Anytime
Other: (list the best time) _________________________________

Please list any team requests (team members or team requests):
___________________________________________________________

Please bring application (with deposit) to the membership desk at
MUSC Wellness Center (Check payable to MUSC Wellness Center)

              
Or mail to: Janis Newton- Harper Student Wellness Center
45 Courtenay Drive, Charleston, SC 29401

             YOU WILL BE NOTIFIED BY DECEMBER 15th, 2009
Please do not apply if you are not ready to lose weight and make lifestyle changes.  You must be available on Thursday evenings – 5:45 – 7:30pm