REGISTRATION
NAME:_____________________________________________________________
ADDRESS:___________________________________________________________
CITY:____________________________________MO:_______________________
PHONE:_________________________CELL PHONE:_________________________
DO YOU TEXT MESSAGE:
YES
NO
EMAIL ADDRESS:_____________________________________________________
ARE YOU ON FACEBOOK:
YES
NO
WEIGHT:___________________________________________________________
AMOUNT PAID:__________________________________CASH
CHECK ______
WHAT DO YOU WANT TO GET OUT OF THE WELLNESS CHALLENGE?
In consideration of the acceptance of my entry in this wellness challenge, I do hereby for myself, my heirs, my executors and administrators,
waive, release and forever discharge any and all rights and claims for damages which I may have or which may hereafter accrue to me, against
Mercer Co. Health Dept and any other persons connected with this event, individually or collectively, from all responsibilities for any injury to
person or property during this event.
By signing this form, I hereby grant permission to the Mercer County Health Department , to take and use photographs and/or digital images of
me for use in news releases and/or educational materials. These materials might included printed or electronic communications. I further agree
that my name and identity may be revealed in descriptive text or commentary in connection with the image (s). I authorize the use of these
images without compensation to me. All negatives, prints, digital reproductions shall be the property of the Mercer County Health Department.
“Spring into Shape” Rules:
1. Kick off weigh-in and final weigh-in will be witnessed by a member of the health
department
2. Kick off weigh in and final weigh in will be done at the health department on the same set
of scales.
3. You must wear basically the same clothing to weigh in on the first day as on the last weigh
in. NO SHOES!!!
4. Weekly sheets must be turned in on the Monday of the following week to receive your
points for turning in the form. Be watching for a link through our web page at
www.mercercountyhealthdepartment.com where you will be able fill out the weekly pages
and resubmit them back to us. If you do not have internet you may email them to
[email protected]. or fax them to 660-748-3634. Or you can simple drop them
off at the office. We must receive them by midnight on Monday in order to get your points
for turning in the form. You may turn them in later to receive your points for activity,
water, weight, fruits, and vegetables, but you will not receive the points for turning in the
form.
5. We are using the honor system for most of the challenge, so please be respectful of
everyone involved.
6. Please, be aware that you do not have to participate in the 5K to be in the wellness
challenge. The 5K is one of the weekly activities.
7. Also, be aware that you may not transfer your wellness challenge entry fee to someone
else for the final prize money or the 5K. In order to qualify for the prizes awarded during
the 5K, you MUST pay the entry fee.
8. No points will be awarded for weekly activities unless you participated in the event. There
are no makeup points available.
9. You may not attend 2 classes in 1 week and none the next week. It is points per week for
activities. We do keep track of attendance.
10. To quality for prize money you must have at least 90% of the points.
11. You must complete the final weigh in and BMI check to be eligible for the maintenance
prize at the weigh in at th1707 E. 9th Street, Trenton, MO 64683 e beginning of next year’s
wellness challenge.
“SPRING INTO SHAPE” POINTS
KICK OFF EVENT
REGISTRATION-----------------------------------------------------------------1 POINT
DAILY
VEGETABLES:
WOMEN:
19-30 YEARS OLD-------------------2 ½ CUPS--------------------3 POINTS
31-50 YEARS OLD-------------------2 ½ CUPS------------------- 3 POINTS
51 AND OLDER-----------------------2 CUPS----------------------3 POINTS
MEN:
19-30 YEARS OLD-------------------3 CUPS----------------------3 POINTS
31-50 YEARS OLD-------------------3 CUPS----------------------3 POINTS
51 AND OLDER---------------------2 ½ CUPS---------------------3 POINTS
FRUIT:
WOMEN
19-30 YEARS OLD-------------------2 CUPS------------------------3 POINTS
31-50 YEARS OLD------------------1 ½ CUPS----------------------3 POINTS
51 AND OLDER---------------------1 ½ CUPS----------------------3 POINTS
MEN:
19-30 YEARS OLD-------------------2 CUPS-------------------------3 POINTS
31-50 YEARS OLD-------------------2 CUPS-------------------------3 POINTS
51 AND OLDER----------------------2 CUPS-------------------------3 POINTS
WATER INTAKE: 8 OUNCES OF WATER-----------------------------------1POINT
UP TO 64 OUNCES (1 CUP EQUALS 8 OUNCES)
ACTIVITY:
150 MINUTES OF MODERATE ACTIVITY WEEKLY-------------25 POINTS
(PERFERABLE IN 30 MINUTE INCREMENTS BUT DOESN’T HAVE
TO BE, CAN BE BROKE UP ANYWAY YOU CHOOSE)
WELLNESS CHALLENGE WEEKLY ACTIVITY----------------------------5 POINTS
TURN IN WEEKLY FORM---------------------------------------------------1 POINT