Biggest Loser Registration Form - Conemaugh Valley School District!

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Registration Packet
For more information or questions contact:
Joanne Peschock
535.5523
[email protected]
Biggest Loser Rules
1. The Conemaugh Valley School District School Health Council has decided to implement the Valley
Biggest Loser Challenge! Individuals may sign up by November 18 @ the after school in-service at
CVHS. Program begins Tuesday, November 30 with private weigh-ins in the High School Nurses
office. Cost is $20.00 for the 12 week challenge. Participants will receive a t-shirt, team support,
and the potential to win great prizes and adopt a healthier lifestyle! We will use a team approach
to implementing the program. Interested participants will have their name put onto a ticket, and
teams will be formed by drawing names out of the hat.
2. Prizes include:
Team Award – Awarded to the team with the biggest percent weight loss for entire team
combined
Biggest Loser Award - Awarded to the participant with the biggest percent weight loss
Biggest Change Award – Awarded to the person with the biggest change (visual, bmi, pounds lost,
lifestyle behavior) - VOTED ON BY PARTICIPANTS
3. The cost to participate in the Biggest Loser Challenge is $20 and must be paid by Friday, November
19, 2010. The Valley Biggest Loser Challenge is open to EVERYONE in our CV Family
(administration, teachers, staff, para-professionals, aides, nurses, custodians, food service
workers, school board members, cleaners, etc – the more the merrier!)
4. The Biggest Loser Challenge runs from November 30 – February 22, 2011.
5. Each individual will have their first weeks weigh in at the CVHS Nurses Office the night of the
informational session. If you cannot make the initial weigh in session please make time to come to the
Nurses office before November 30, 2010. If you cannot make it to the closing session please make
time to come to the Nurses office before February 22, 2011 to do your last weigh-in. If you have not had
your last weigh in by February 22, 2011 you will not be eligible for any of the awards.
6. Each week your team captain needs to report the weigh loss of each individual in your team. If you are only
doing the individual challenge and are not participating in the team challenge you will need to report your
own loss.
7. Please, only the team captain should report the team’s weight loss for the week. The team captain must
report pounds lost from each individual, NOT how much each team member weighs. Ex. On the “Mean
Green Team” Susie lost 4 pounds, Henry lost 5 pounds, John lost 1 pound.
8. Weight loss/gain needs to be reported to Joanne Peschock every Friday by 1:00 pm.
9. The preferred way to report your weight loss each week is through email. PLEASE email your results to
[email protected] and put in the subject line BIGGEST LOSER.
10. There will be multiple classes and campaigns held during the biggest loser challenge. There is a schedule of
classes in you packet. Classes are optional to attend – but if you are interested, you must pre-register w/ Joanne
Peschock . Attendance at these classes is not mandatory, but great information will be covered that will aid in
your weight loss goals. On-site, instructor lead classes, one on one with a dietitian and numerous newsletter
campaigns about healthy eating will be implemented – TAKE ADVANTAGE – they are FREE because you have
Highmark Blue Cross Blue Shield insurance.
11. The last weigh in will be held at the nurses office during the Biggest Loser closing program ceremony
(February 22, 2010 at 3:10 pm at the High School). A FREE healthy luncheon will be provided for participants!
Awards will be given at this time. If you cannot make it to this event please make time to come to the Nurses
office before the closing program.
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Biggest Loser Registration Form
Individual (I will participate on my own)
Team (Please include me on a team to be chosen at the In-service on 11.18.10
Name: _________________________________________
Address: _______________________________________
Phone:____________________________________ Email:
Emergency Contact Information
Name: _____________________________________________________
Address: ___________________________________________________
Phone: _______________________________________ Alternative number:
Relationship: __________________________________ Email: ___________
Participating in the _____team challenge ______individual challenge (those participating in the team will
automatically be entered in the individual challenge.)
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General Liability Release, Assumption of Risk, and Waiver Claims
In consideration of being permitted to participate in exercise, athletic endeavors, or other activities
(collectively “athletic endeavors”) for the Valley Biggest Loser Challenge, the undersigned participant(s) do
each agree that the Conemaugh Valley School District, the Biggest Loser program, its heirs, assigns, and
agents, and any and all other persons or entities involved in its athletic endeavors, together with all
subcontractors, employees or volunteers, SHALL NOT BE LIABLE for injury or death to the undersigned
participant(s), their heirs, assigns and agents, or any loss due to theft of or damage to their property or for
any other consequential incidental damages caused in any manner whatsoever where any such liability is
attributable to the absence of ordinary or even slight care by the Conemaugh Valley School District, the Valley
Biggest Loser Challenge, in the conduct of athletic endeavors.
Furthermore each of the undersigned DOES HEREBY WAIVE any and all claims or causes of action against the
Conemaugh Valley School District, the Valley Biggest Loser Challenge, which he or she may have by reason
thereof AND DOES HEREBY RELEASE AND HOLD HARMLESS the Conemaugh Valley School District, the
Valley Biggest Loser Challenge, from any or all claims or causes of action that he or she may have from the
beginning of time, now, and in the future. Each of the undersigned further agrees not to bring or cause to
be brought any suit or any such claim or cause of action and acknowledges that the releases and waivers
referred to herein shall apply regardless of whether liability is asserted on the basis of contract, strict liability,
ordinary negligence or gross negligence.
I also affirm that I am voluntarily participating in athletic endeavors and using the facilities, and further
acknowledge that I know, understand, and appreciate the inherent risks of such participation and use (ranging
from minor injuries such as sprints, to major injuries such as heart attacks, ankle and knee injuries, to catastrophic
injuries such as death or paralysis). I assume full responsibility for any and all injuries or damages from
participating in athletic endeavors and facility use, which may occur to me as a result of such
participation.
Each of the undersigned further acknowledge that the execution this Release, Assumption of Risk, and Waiver is
continuing in nature, that it is his or her free and voluntary act, that he or she does not intend to participate
in athletic endeavors at the Conemaugh Valley School District, the Valley Biggest Loser Challenge until or
unless he or she has had full opportunity to inspect its exercise and athletic facilities and to receive all
information from the Valley Biggest Loser Challenge that might bear on his or her decision to participate,
and that he or she is under no duress or undue influence.
Furthermore, each of the undersigned intends both that he or she be legally bound hereby, and, in the event
of his or her death, that this release and waiver shall be binding on his or her estate, heirs, beneficiaries or
any other successors in interest.
This Release, Assumption of Risk, and Waiver shall be construed under the laws of the
Commonwealth of Pennsylvania.
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SIGNATURE BELOW VARIES THAT EACH OF THE UNDERSIGNED HAS READ AND FULLY UNDERSTANDS THE
FOREGOING and further certifies that information provided in his or her entry forms and /or personal data
sheets is true and complete:
IN WITNESS WHEREOF, each of the participants sets forth his or her hand at the time and on the date below
written.
(Signature)
(Date)
Photo Consent:
I hereby give permission for ______________________ to be photographed and/or filmed for
promotional or media reasons (Extension website, Newspaper, Newsletters, Facebook, etc.).
(Signature)
(Date
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Team Form
Team Name: _______________________________________________
Team Captain: ______________________________________________
Team Captain’s e-mail: _______________________________________
Team Captain
Members:
INITIAL
11/30
Weight % Loss
5
12/31
BMI
1
12/03
Weight
% Loss
6
1.07
Weight
% Loss
11
2/11
Weight
% Loss
2
12/10
Weight
% Loss
7
1/14
Weight
% Loss
12
2/18
Weight
% Loss
Weight
7
3
12/17
Weight
% Loss
8
1/21
Weight
% Loss
FINAL
2/22
% Loss
BMI
4
12/23
Weight
% Loss
9
1/28
Weight
% Loss
10
2/04
Weight
% Loss
Classes & Wellness Offerings
On-site Programs:
Eat Well for Life℠ I is a lifestyle improvement program promoting wellness and long-term weight management through
balanced nutrition. Participants learn to make healthful food choices and are encouraged to adopt nutrition practices to
achieve a balanced lifestyle and long-term weight management. Participants receive a participant manual, including
recipes. This is a six-week, one hour per week, course.
Start date: Fridays, 1.07.11
End date: 2.11.11
Time: 1:20 pm – 2:20 pm
Location: Class will rotate between buildings
Register by: 12.20.10
Personal Nutrition Coaching℠ is individual nutrition coaching by a registered dietitian/licensed nutritionist to address
weight management, heart health, diabetes and other health issues. An individualized plan is created that can be easily
integrated into the individual’s lifestyle. Members are allotted one initial session and 6 follow-up sessions per calendar
year.
Start date: 1.07.11
Time: will vary, we need three, back to back, one hour appointments for the dietitian to be brought on site
Location: CVHS, ETES, CVES
‘Tis the Season to Lighten Up℠ is an 8-week holiday wellness newsletter campaign designed to help individuals maintain
healthy habits, including diet, exercise and stress management, throughout the holiday season.
Start date: 11.20.10
End date: 1.3.11
Location: This is an email newsletter campaign. You will receive the newsletter via email from Joanne Peschock
Eat Well for Life℠ Newsletter Campaign is an 8-week interactive, self-guided health challenge to help participants build
a better diet. Participants receive one introduction and 8-weekly action-oriented newsletters that contain articles,
activities and strategies in an easy-to-read style that demonstrates how to make healthy eating simple and fun.
Start date: 1.03.11
End date: 2.21.10
Location: This is an email newsletter campaign. You will receive the newsletter via email from Joanne Peschock
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