WHO: "[enter business name]" employees

WHAT: A Larger Life in a Smaller Your Weight Loss Competition

WHERE: "[enter location of weigh-ins]"

WHEN: [dd/mm/yyyy] to [dd/mm/yyyy] Compete as an individual and as teams in this fun, motivating challenge encouraging healthy eating habits, physical activity, weight loss, and most importantly…ACCOUNTABILITY, SUCCESS, & ENJOYMENT!

BASIC PROGRAM STRUCTURE:

Weekly Weigh-Ins: [enter date and time]

Weekly Food or Exercise Challenges

Food and Activity Journaling

A LARGER LIFE…in a smaller you

Competition Details

Looking for a reason to get in shape, lose weight, and look fantastic

for the Holidays, for a reunion, for LIFE? Get together with your

co-workers and form a team to compete in A LARGER LIFE

competition.

- Each participant pays $65.00* to participate

- Each participant must complete:

o Registration Form

o Exercise Readiness Form

Baseline Fitness Assessment Form (optional*)

*Participants can earn back their $65.00 by:

Participating in Weekly Weigh-Ins

Journaling in Activity and Food Logs

Completing Weekly Challenges

Losing Weight (or maintaining)

Each week participants will set a short term (week) goal. Those who

achieve their goal, lose or maintain their weight, and complete the

weekly challenge, will receive $5.00 each week ($5 x 13 weeks = $65.00

back into the pockets of your loose jeans!)

Although this is a steep investment to pay upfront, the money will act as

a HUGE motivator for you, while you learn to make healthy behaviors

part of your daily routine.

Teams with the largest % weight loss will win the pot of money

remaining from participants who could not earn back their weekly

$5.00! (for those not looking to lose weight, prizes will also be awarded

to those who maintain their weight and improve their fitness level!)

REGISTRATION FORM: (one per team)

Team Members: Team Name:

"[Insert Team Member Name]" "[Insert Team Name]"

"[Insert Team Member Name]"

"[Insert Team Member Name]"

"[Insert Team Member Name]"

"[Insert Team Member Name]"

Minimum of 3 members per team!

Return Registration Form and ALL supporting documents to

"[enter coordinator's name]" by [dd/mm/yyyy] .

Email: "enter email address"

Drop Off: "[enter location to return registration materials]"

Phone: "[enter coordinator's phone number]"

REMEMBER TO INCLUDE:

Registration Form

Each Participant’s Exercise Readiness Form

Each Participant’s Fitness Form (*optional if requested by coordinator)

Exercise Readiness Questionnaire

NAME "[First Name]" [M.I.] "[Last Name]" AGE [years] DATE"[Today's Date]"

ADDRESS [Street] [City] [State]

TELEPHONE: (home)[555-555-5555] (business)[555-555-5555]

OCCUPATION:"[e.g. secretary]" DEPARTMENT:"[Co. Dept]"

MARITAL STATUS: Single Married Divorced Widowed

SPOUSE NAME: "[ Name]"

PERSONAL PHYSICIAN: "[Physician's Name]" LOCATION: "[Clinic Name/City]"

Reason for last doctor visit? Date of last physical exam:[Date]

Have you previously been tested for an exercise program? YES NO YEAR:[date]

LOCATION OF TEST:[Clinic/City]

Person to contact in case of Emergency: "[ Name]" Phone:[555-555-5555] (relationship)

PLEASE CHECK YES or NO

PAST HISTORY FAMILY HISTORY PRESENT SYMPTOMS

(Have you ever had?) YES NO (Have any immediate family YES NO (Have you recently had?) YES NO

or grandparents had?)

High Blood Pressure… Chest pain/discomfort…

Any heart trouble…… Heart Attacks…………. Shortness of breath……

Disease of the arteries. High blood pressure…… Heart palpitations…….

Varicose Veins……... High Cholesterol……… Skipped heart beats….

Lung Disease………. Stroke…………………. Cough on exertion……

Asthma……………. Diabetes………………. Coughing of blood……

Kidney Disease…… Congenital Heart Defect Dizzy Spells………….

Hepatitis………….. Heart Operations…….. Frequent Headaches….

Diabetes…………… Early Death…………... Back Pain…………….

Heart Murmur…….. Other family illness: Orthopedic Problems…

HOSPITALIZATIONS: Please list recent hospitalizations (Women: do not list normal pregnancies)

Year Location Reason

Any other medical problems/concerns not already identified? YES NO (Please list below)

Have you ever had your cholesterol measured? YES NO If yes, TC Value: Date:[mo/yr]

Are you taking any Prescription or Non-Prescription medications: YES NO (include birth

control)

Medication Reason for Taking For How Long?

Do you currently smoke? YES NO If so, what? Cigarettes Cigars Pipe

How much per day: <1/2 pack ½ - 1 pack 1 ½ -2 packs >2 packs

Have you ever quit smoking? YES NO When? [mo/yr]

How many years and how much did you smoke?

Do you drink any alcoholic beverages? YES NO If Yes, How much in 1 week?

Beer (cans) Wine (glasses) Hard Liquor (drinks)

Do you drink any caffeinated beverages? YES NO If Yes, How much in 1 week?

Coffee (cups) Tea (glasses) Soft Drinks (cans)

ACTIVITY LEVEL EVALUATION

What is your occupational activity level? Sedentary Light Moderate Heavy

Do you currently engage in vigorous physical activity on a regular basis? YES NO

If so, what type? How many days per week?

How much time per day? <15 min 15-30 min 30-45 min >45 min

Do you ever have an uncomfortable shortness of breath during exercise? YES NO

Do you ever have chest discomfort during exercise? YES NO If so, does it go away with rest?

Do you engage in any recreational or leisure-time physical activities on a regular basis?

YES NO If so, what activities:

On average: How often: days/week For how long? minutes/session

Are you currently following a weight reduction diet plan? YES NO

If so, how long have you been dieting? months Is the plan prescribed by your doctor? YES NO

Have you used weight reduction diets in the past? YES NO

If yes, how often and what type?

Please indicate the reasons why you want to join the exercise program.

To lose weight Doctor’s recommendation For good health

Enjoyment Release of Tension Other

Improve Physical Appearance

STAFF USE:

Fitness Assessment Form

Prior to competing in the weight loss challenge, please complete the fitness assessments below to

measure your current fitness level. After the program concludes, you will be asked to repeat the

fitness assessments to measure your improvements in fitness levels. Then you will have more

than just a number on the scale to illustrate the numerous health and fitness benefits you will be

receiving from your healthy lifestyle behaviors!

WHAT YOU WILL NEED:

Scale and Measurement Rod (to measure your height and weight)

Stop Watch or watch with the second hand

Track, Treadmill, or Road Route of 1 Mile

Tennis Shoes

Comfortable Exercise Clothing

Pen and This Paper to Record Results

Assessment 1: Body Mass Index --- Classification of Body Fat

Record Your Weight: ___________ (pounds) * Your BMI will be

Record Your Height: ___________ (inches) calculated by Wellness Coord.

Assessment 2: Muscular Strength and Endurance

# of Push –Ups to Fatigue: ________ *Push-ups must be in a row without resting

Females: Position hands under shoulders, and knees on ground

Males: Position hands under shoulders, and toes on ground (knees off ground)

All: Keep spine in neutral/flat position throughout motion

Assessment 3: 1 Mile Walk --- Cardiovascular Fitness

STEP 1: Record Resting Heart Rate: ______ beats per minute

STEP 2: Warm-up for 5 minutes with a light, easy walk

STEP 3: Rest 2-3 minutes (optional)

STEP 4: Start stopwatch and walk 1 mile (Try to complete the mile as fast as you

can, while still walking….no jog/run)

STEP 5: Stop watch at 1 mile mark

STEP 6: Record Your Heart Rate: ______ beats per minute

STEP 7: Continue walking at a slow pace for 5-10 minutes to cool-down.

*It’s a good idea to perform these tests in the listed order or on separate days to

prevent premature fatigue!!

Doing the assessments with a friend is helpful and motivational!

Pre-Competition

HOMEWORK!

Time to Walk 1 Mile: _______ (minutes: seconds)

A Larger Life in a smaller you

Coordinator Directions:

1. Promote Weight Loss Challenge using the flyer provided in the Challenge Details 2. Distribute Registration Materials to interested participants and employees 3. Collect registration materials (along with the $65 fee) and analyze exercise readiness

questionnaires to verify all participants are healthy to begin the exercise and nutrition challenge (some participants may need permission from their physician, others may not be suitable for the challenge due to preexisting conditions and medications)

4. Schedule the initial weigh-in and notify participants of location , date, and time 5. Also provide the participants with the challenge sheet and explain they must track and

complete the weekly challenges to qualify for the weekly $5.00 pay-back. 6. Use the Challenge Tracking Spreadsheet to track the weights and progress of

participants each week. 7. Coordinator’s can also distribute the Mini-Activity Logs so participant’s can track weekly

progress. 8. Each week, participants are required to:

a. Attend the weigh-in (or report weight if you choose not to have on-site weigh-ins)

b. Complete the weekly challenge (as listed on the challenge sheet) c. Lose or maintain their weight from the previous week’s weight

9. If the participants complete all 3 requirements, return he/she $5.00 from their registration fee.

(Participants will have a chance to earn back all $65 if they succeed each week of the challenge) 10. On the last week of the challenge, have all participants complete the fitness

assessments again, if you required them at the beginning. Compare the results of both assessments to identify improvements in fitness and weight!

11. Acknowledge the winners and all participants at the end of the challenge (in the company newsletter, a flyer on the bulletin board, a picture on the intranet, etc)

All money that is not returned to participants can be distributed to the overall winner and/or team at the end of the competition…no need for the company to spend money on incentives or prizes!

Fruit

Grains

Protein Vegetables

Dairy

Fruit

Grains

Protein Vegetables

Dairy

Starting Weight: ______ Current Weight: _______

Weight Loss to Date: ______ Weekly Weight Loss: _______

% Weight Loss: ______

Date:____

Date:____

Physical Activity

Sun Mon Tue Wed Thurs Fri Sat

Cardio Minutes

4-5 days ________ ________ ________ ________ ________ ________ ________

Strength Training

2-3 days

Stretching 7

days

BREAKFAST

LUNCH

DINNER

Fruit

Grains

Protein Vegetables

Dairy

Fruit

Grains

Protein Vegetables

Dairy

Sweets, Fats, Drinks

150 calories/box

BREAKFAST

LUNCH

DINNER

Fruit

Grains

Protein Vegetables

Dairy

Fruit

Grains

Protein Vegetables

Dairy

Sweets, Fats, Drinks

150 calories/box

Water

Water

WEEK 1

October 6-12

WEEK 2

October 13-19

WEEK 3

October 20-26

WEEK 4

October 27- Nov 2

WEEK 5

November 3-9

WEEK 6

November 10-16

WEEK 7

November 17-23

Challenge: Eat one fruit serving AND one vegetable serving at lunch AND dinner on five days of the week!

Challenge: Take the stairs to work all 5 days this week. If your office is on the first floor, park in the farthest parking lot spaces.

Challenge: Exercise 3 days this week for 30+ minutes each day.

Challenge: Incorporate 2 days of strength training to your exercise program.

Challenge: Include fish into 2 meals this week.

Challenge: Exercise at least 4 days this week for 30+ minutes each day.

Challenge: Walk 15 minutes on at least 5 breaks this week.

NAME ______________________________

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Veg: _______ _______ _______ _______ ______ ______ _______ _______ _______ _______ _______ ______ ______ _______ Fruit: _______ _______ _______ _______ ______ ______ _______ _______ _______ _______ _______ ______ ______ _______

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

Monday Tuesday Wednesday Thursday Friday AM PM AM PM AM PM AM PM AM PM

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Mode: _______ ________ ________ _________ ________ ________ ________ Time: _______ ________ ________ _________ ________ ________ ________

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Dish: _______ _______ _______ _________ ________ ______ ________

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Mode: _______ ________ ________ _________ ________ ________ ________ Time: _______ ________ ________ _________ ________ ________ ________

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

WEEK 8

November 24-30

WEEK 9

December 1-7

WEEK 10

December 8-14

WEEK 11

December 15-21

WEEK 12

December 22-28

WEEK 13

December 29- Jan 4

FINAL WEIGH-IN – "[enter date]" !

WINNERS ANNOUNCED!

Challenge: Include 2 vegetable and 1 fruit serving at 2 meals on 5 days this week.

Challenge: Complete the circuit challenge this week!

Challenge: Attend a Flexibility Session – Choose from an AM, PM, or NOON session (M-T-W-R-F)

Challenge: Consumer 3 servings of low-fat Dairy on at least 5 days this week.

Challenge: PUT IT ALL TOGETHER!

2 vegetables + 1 fruit at 2 meals on 5 days

Exercise (cardio) 3 days for 30+ minutes

Strength Train on 2 days this week

Consume fish twice this week

Consume 3 servings of dairy on 5 days this week

Perform a flexibility routine once this week

Challenge: Exercise 30+ minutes on 5 days this week

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Veg: ______ _______ _______ _______ ________ _______ _______ ______ ______ _______ ______ ______ ______ ______

Veg: ______ _______ _______ _______ ________ _______ _______ ______ ______ _______ ______ ______ ______ ______ Fruit: ______ _______ _______ _______ ________ _______ _______ ______ ______ _______ ______ ______ ______ ______

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Monday Tuesday Wednesday Thursday Friday

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Mode: _______ ________ ________ _________ ________ ________ ________ Time: _______ ________ ________ _________ ________ ________ ________

Sunday Monday Tuesday Wednesday Thursday Friday Saturday _______ ________ _______ _________ ________ ________ ________ _______ ________ _______ _________ ________ ________ ________ _______ ________ _______ _________ ________ ________ ________