Available Classes for Registration

Wednesday, February 29th, 2012, 11:00 AM to 12:00 PM
Wednesday, February 29th, 2012, 7:00 PM to 8:00 PM

Registration Information

1. First name
2. Last name
3. Email
4. Phone (daytime)
5. Address 1
6. Address 2
7. City
8. State
9. Zip

1. Liability

   I agree that the North Carolina Cooperative Extension Service and the North Carolina Division of Public Health shall not be liable for any claims, demands, actions, or cause of action. Read liability details

   Liability Details

   I agree that the North Carolina Cooperative Extension Service and the North Carolina Division of Public Health shall not be liable for any claims, demands, actions, or cause of action, whatsoever, to my person or property arising out of or connected with my participation in this weight-management program. I do hereby forever release and discharge the said North Carolina Cooperative Extension Service and the North Carolina Division of Public Health, its employees, agents, or servants from all such claims, demands, injuries, damages or cause of action. With this program having been explained to me and all of my questions answered to my satisfaction, I consent to participate in this weight-management program fully aware of the procedures and risks that may be involved. Close

2. Physician Approval / Waiver of Medical Exam

   • I hereby make a knowing and informed waiver of the suggested medical exam and certify that I am physically sound and can proceed with this weight-management program. Read medical details

     Explanation of Medical Options

     This is a weight-management program consisting of healthy eating and physical activity, with an emphasis on your individual capabilities. There exists the possibility of certain biological changes occurring during your participation in the program. These changes include, but are not limited to: risk of gallstones with rapid weight loss, risk of fractures if you have osteoporosis, abnormal blood pressure, fainting, disorder of the heartbeat and, in rare instances, heart attack or death. Thus, prior to participating in this program it is advisable that you consult a physician. If you choose not to consult a physician, the waiver option must be executed. Close

   • I hereby stipulate that I am physically sound and that, by the time I begin this weight-management program, I will have medical approval from my health-care provider to proceed with a normal routine of physical activity and healthy eating.

3. State Health Plan for Teachers and State Employees Member Verification

   I understand that my participation in this Eat Smart, Move More, Weigh Less class series is contingent upon my being a member of the State Health Plan for Teachers and State Employees at the start and throughout the duration of this 15-week program. Read member verification details

   Details about Member Verification

   The State Health Plan for Teachers and State Employees (Plan) is pleased to sponsor the "Eat Smart, Move More, Weigh Less" program for our adult members whose primary health insurance is through the Plan. Please sign the statement below verifying your membership in the Plan.

   I am a member of the State Health Plan for Teachers and State Employees (Plan). I understand that my participation in this Eat Smart, Move More, Weigh Less class series is contingent upon my being a member of the Plan at the start and throughout the duration of this 15-week program. To the best of my knowledge, I am eligible to participate in this program. I understand that Eat Smart, Move More, Weigh Less will not share my name and contact information with the Plan unless required to do so to comply with State or Federal Law. Any results of my participation in this program will not be shared with the Plan. Close

4. Weekly Report Card and Follow Up

   • You can use my weekly report card data, I understand that my name will not be associated with my data.
   • You can email me for follow up, I understand that my email will not be shared with anyone.
   Read follow-up details

   Follow-up Details

   Thank you for participating in Eat Smart, Move More, Weigh Less. We hope you will enjoy the program and learn strategies that you can use for a lifetime. We would like your help in evaluating this program.

   Your participation is voluntary. We would like your permission to use the data that you record on the weekly report card. Your name will not be associated with your data nor will your name be used in any way. In addition, we would like your permission to email you after the program to see how you are doing. Your participation in this is voluntary. Your email will not be shared with anyone.

   If you have any questions, contact Dr. Carolyn Dunn (919.515.9142, Carolyn_Dunn@ncsu.edu) at NC State University. If you feel you have not been treated according to the descriptions in this form, or your rights as a participant in research have been violated during the course of this project, you may contact Dr. Arnold Bell, PhD, Chair of the NCSU IRB for the Use of Human Subjects in Research Committee, Box 7110, NCSU Campus (919.515.4420) or Mr. Matthew Ronning, Assistant Vice Chancellor, Research Administration, Box 7514, NCSU Campus (919.513.2148). Close

5. How did you hear?

   How did you find out about Eat Smart, Move More, Weigh Less? Select... Someone I know recommended it It is part of a wellness initiative at my work I read about it on a blog or website I read about it in the newspaper I read about it in a trade publication/business journal I heard about it on the radio I saw it on television It showed up in internet search results Other Other reason

Please note: By making payment for your class you acknowledge and understand that WE DO NOT ISSUE REFUNDS UNLESS THE CLASS IS CANCELLED DUE TO LOW PARTICIPATION.