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KU Weight Management Program

Application Form

All the fields are required. Use N/A where question not applicable.
No decimals values for numeric figures. Whole numbers only.

First Name    MI    Last Name
City    ST    Zip
Home Phone #
Cell Phone #
Work Phone #
Email Address
Age   years
Date of Birth   format: MM/DD/YYYY
Height   feet      inches
Weight   pounds
What city would you like to participate in?
Have you participated in one of our programs before?
If yes, when and what program?
How did you hear about us?     (friend, newspaper, flyer, etc)
** Race and Ethnicity are collected for aggregate descriptive purposes only **
Do you have any medical problems that would prevent you from participating in a regular walking program?
If yes, please explain:
Have you had any surgery in the past 12 months?
If yes, please explain:
Have you participated in a regular exercise program over the past 6 months which consists of at least 20 minutes of activity, 3 days per week?
If yes, please explain:
Do you have any special diet restrictions?  (vegetarian, lactose intolerant, etc.)
If yes, please explain:



For additional questions concerning the KU Weight Management Programs, please feel free to contact us: