Fit for Life (FFL) Membership Application

Please complete the form. Print clearly. The application may be submitted to: Derek Arledge Cambridge Public Health Department ▪ Men’s Health League 119 Windsor Street ▪ Cambridge, MA 02139 ▪ FAX: (617) 665-3888 ▪ TEL: (617) 665-3686

Name Date of Birth

Street Address

City/State Zip

Telephone (Home) Cell

1. How do you describe your cultural background? (Mark ALL that apply.)

□ American Indian or Alaska Native □ Asian □ Black or African American □ Caucasian □ Hispanic or Latino □ Native Hawaiian or Other Pacific Islander □ Other, Explain______

2. What language do you speak often at home?

□ English □ Spanish □ Haitian Creole □ Other (What language?)______

3. How did you hear about the Fit for Life (FFL) program?

□ Doctor □ Friend or relative □Flyer □ Other: Please describe: ______

4. Have you ever or are you currently participating in any exercise programs or training classes? Please check all that apply.

□ Weight training □ Walking □ Structured fitness class □ Stationary cycling

□ Jogging □ Recreational sports □ Other: Please describe: ______

5. Do you currently have a primary care physician? □ Yes □ No

6. If you marked “Yes” to question 5, what is the name of your primary care physician? If you marked “No”, can we help you find one? □Yes □ No

(Please fill out the back of the page) 7. Do you currently have health insurance? If no, can we help you enroll in a health plan? □ Yes □ No

8. Check (if any) the health issues below that you have experienced.

Diabetes Heart Disease Stroke Overweight/Obese High blood pressure

High Cholesterol

Do you currently have any fitness goals? If so, how would your participation in the Fit for Life program assist you in achieving this goal?

9. What makes you a good candidate for the Fit for Life program?

______

Completion of this form does not guarantee your inclusion in the upcoming cycle.

Do not write below this line

Interviewer: ______

Interviewee: ______

Notes:______

______