(Please be specific when filling out this form)
Fill out and send as attachment to "info@yforme.org"
or you can mail it to us at:
YOFF, 3261 Marydon Dr, Baton Rouge, La. 70814
Or email at info@yforme.org
To contact us: 225-571-5186 or email to info@yforme.org
Name: ________________________________________________________
Address:_______________________________________________________
Home phone number: ____________________________________________
Age: ______
Date of birth: ___________________________
Height: _____
Weight:_____
School: _______________________________________________________
Father’s name: __________________________________________________
Fathers Employer: _______________________________________________
Address of Employer: ____________________________________________
Work number: __________________________________________________
Mother’s name: _________________________________________________
Mothers Employer: ______________________________________________
Address of Employer: ____________________________________________
Work number: __________________________________________________
Name of your primary physician: ___________________________________
Do you have health insurance: _______?
Are you currently on any weight loss medication: ___Yes ___No?
Have you ever had a physical: _____ if yes, when was your last physical ______________________?
Name of Doctor who performed your last physical: _______________________________________
Are you currently on medication: _____ If yes, please list them and why:
Have you ever broken or fractured a bone? _____ If yes, list them in order of
Incident:________________________________________________________________________________
Have you ever had surgery because of being over weight? _____ If yes, list procedure and date of operation
Have you been diagnosed as ADD, or ADHD? _____ If yes, list any medication you are on:
Have you ever participated in athletics? ____ If yes, list sport(s) and name of school or team:
Please write a brief comment on why you want to join in the YOFF program and what are your goals for your health: (ex. How much weight do you want to loose? How willing are you to reach your goals?)
