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(for all applicants) Name: ______________________________________ Male / Female Address:_________________________________________________ Department:__________________________________________________ Phone:_________________ Email ______________________ Age: ___ Height ______ Weight _______ Do you smoke? ______ Medical Concerns: Diabetes, Heart Disease, High Blood Pressure, High Other _______________________________________________________ * Please circle any of the above that apply to you. List Medications: ____________________________________ How many days per week do you participate in exercise? __________ How many pounds do you need to lose? _________ What is your primary goal for weight loss? ______________________ Has a Doctor ever told you not to exercise? ____________________ If so, why? __________________________________________ What is your waist measurement? ______________ Do you have others you would like to have on your team? Please list: ______________________________________________________________ Please bring this application to the membership desk at the MUSC Wellness Center 45 Courtenay Drive, Charleston, SC 29401 
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