NAACP 2016 HEALTH FITNESS CHALLENGE REGISTRATION FORM
I am registering as a Participant in the NAACP DC Branch 2016 Health Fitness Challenge.  The NAACP DC Branch is implementing a 12-month Health Program to empower African-American women to adopt healthy lifestyles through gardening, cooking, healthy eating and physical activity.  This Health Program will include monthly activities, fitness programs and online coaching from 2016 through 2017.  
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FIRST NAME *
LAST NAME *
PHONE # *
EMAIL ADDRESS *
MAILING ADDRESS *
We send informational mailings about the Health Program activities
CITY *
STATE *
ZIPCODE *
WARD *
FACEBOOK NAME
Please provide your name on Facebook, so we can friend you through our Facebook page.  We utilize Facebook and social media for online coaching and motivational support throughout the program
TWITTER NAME
Please provide your Twitter handle.  We utilize Twitter and social media for online coaching and motivational support throughout the program
INSTAGRAM NAME
Please provide your Instagram handle.  We utilize Instagram and social media for online coaching and motivational support throughout the program
AGE *
GENDER *
GOALS *
Required
AREAS OF INTEREST *
Required
GYM MEMBERSHIP *
Are you currently a member of a Gym or Fitness Center?  If yes, provide the name.
NAME OF GYM OR FITNESS CENTER
If you are a member of a Gym, please provide the name of the Gym
MALE OR FEMALE PERSONAL TRAINER *
Do you have a preference of a male or female personal trainer?
PRIMARY CARE PHYSICIAN *
Do you have a Primary Care Physician?
PHYSICIAN'S NAME
PHYSICIAN'S PHONE #
WEIGHT LOSS SPECIALIZED PRIMARY CARE PHYSICIAN *
Would you be interested in meeting with a Primary Care Physician, specializing in weight loss to discuss specific medical or diet-related concerns?
EMERGENCY CONTACT NAME *
EMERGENCY CONTACT PHONE # *
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