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First Name *

Last Name *

Phone Number *

Email Address *

What is the best way for us to contact you? *

After the three introductory classes, does meeting on Tuesdays 4 - 6 p.m. or Saturdays 10 a.m. - 12 p.m. work for you? *

Children are welcome. If you plan on bringing your children, please list how many children you have and their ages. *

In order to begin the program, participants must attend our introductory classes on Saturdays from 1 – 3 p.m. for three weeks in a row. Are you able to attend these classes? *

If enrolled in the program, you will be required to: Track your minutes of physical activity, track your food intake, contact your buddy once a week, bring your Achieve notebook to class every week. Are you willing to do these things? *

Are you planning to move within the next six months? *

How important is it for you to complete this program? *

How confident are you that you can complete this program? *

What challenges do feel you may have in attending the meetings? *

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