<p> Fit for Life (FFL) Membership Application</p><p>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</p><p>Name Date of Birth</p><p>Street Address</p><p>City/State Zip</p><p>Telephone (Home) Cell</p><p>Email</p><p>1. How do you describe your cultural background? (Mark ALL that apply.)</p><p>□ American Indian or Alaska Native □ Asian □ Black or African American □ Caucasian □ Hispanic or Latino □ Native Hawaiian or Other Pacific Islander □ Other, Explain______</p><p>2. What language do you speak often at home?</p><p>□ English □ Spanish □ Haitian Creole □ Other (What language?)______</p><p>3. How did you hear about the Fit for Life (FFL) program? </p><p>□ Doctor □ Friend or relative □Flyer □ Other: Please describe: ______</p><p>4. Have you ever or are you currently participating in any exercise programs or training classes? Please check all that apply.</p><p>□ Weight training □ Walking □ Structured fitness class □ Stationary cycling</p><p>□ Jogging □ Recreational sports □ Other: Please describe: ______</p><p>5. Do you currently have a primary care physician? □ Yes □ No</p><p>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</p><p>(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</p><p>8. Check (if any) the health issues below that you have experienced.</p><p>Diabetes Heart Disease Stroke Overweight/Obese High blood pressure</p><p>High Cholesterol </p><p>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?</p><p>9. What makes you a good candidate for the Fit for Life program?</p><p>______</p><p>Completion of this form does not guarantee your inclusion in the upcoming cycle.</p><p>Do not write below this line</p><p>Date:</p><p>Interviewer: ______</p><p>Interviewee: ______</p><p>Notes:______</p><p>______</p><p>______</p>