ROCHESTER INSTITUTE OF TECHNOLOGY
Weight Watchers at Work
Registration Form
Bring your completed registration form to the Renewal Open House (last week of prior session) or Week 1 meeting. If
paying by check or credit card, please do so directly with the Weight Watchers leader; this registration form is still
required.
At least 15 people must be registered by Week 1 in order to run the program
Meeting Days/Time: Thursdays 12:00 p.m. – 12:45 p.m.
Name:
___________________________________
Employee #: _______________________
E-Mail:
___________________________________
Work Phone: _______________________
LIFETIME MEMBER INFORMATION
 I am not a Lifetime Member
 I am a Lifetime Member within 2 pounds of my goal weight
Lifetime Members who are within 2 pounds of their goal and have weighed in during the previous month do not pay. These
members do not count towards the minimum requirement to run the program.
 I am a Lifetime Member within 2 to 7 pounds of my goal weight
Lifetime Members who are within 2 to less than 7 pounds over their goal can attend but will pay a weekly pro-rated fee directly
to the Weight Watchers leader until they are back to a free status. These members do not count towards the minimum
requirement to run the program. Payroll deduction is not allowed.
 I am a Lifetime Member 7 pounds or more away from my goal weight
Lifetime Members who are 7lbs or more away from their goal will count towards the minimum requirement to run the program
and are required to pay the full session fee. Weight Watchers may issue a refund for future meetings if you move back into
free status. Payroll deduction is allowed.
PAYMENT INFORMATION
Session length may vary. This will be determined at the Week 1 meeting. The cost of the 12-week session is $156.00 and the
cost of the 17-week session is $186.00. **Renew Early Discount (RED) for current members can get 15%off their next series.
Complete registration form & submit to your leader anytime between May 5 – May 12, 2016.
 CREDIT CARD
Payment information must be provided directly to the Weight Watchers leader at a meeting
 CHECK
Checks must be made payable to Weight Watchers and given to the Weight Watchers leader
PAYROLL DEDUCTION – Full Amount @ $156 (12-week Session) or $186 (17-week Session)
The per pay period payroll deduction amount will be calculated by dividing the total session amount by the number of pay
periods within the session dates. This selection must be made by Week 1 of the session; otherwise you must pay by
credit card or check.
PAYROLL DEDUCTION - Continuing Member in Current Session Renewing Early @ $132.60 (12-week
Session) or $158.10 (17-week Session)
EMPLOYEE SIGNATURE
If I elected payroll deduction, I authorize RIT to reduce my salary by the applicable after-tax deduction from my paycheck for the Weight
Watchers at Work program. If I leave employment before all deductions have been made, I authorize RIT to withhold the remaining
payments owed from my last paycheck. Payroll deduction cannot be cancelled during the session.
I understand that refunds will only be processed by Weight Watchers for pregnancy or illness with a doctor’s note, termination of
employment with a letter from employer or for lifetime members who meet specific criteria. The membership book and program
materials must be returned with the doctor’s note or letter from employer as applicable, and refunds will be pro-rated.
_____________________________________________
Employee Signature
__________________________
Date
For questions about registering, contact [email protected] or visit the Weight Watchers page on the Better Me website. For
questions specific to the Weight Watchers program, please contact the Weight Watchers hotline at 1-866-204-2885 or email
[email protected].
Rev 9/2//2015