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 (Have you ever had?)

YES

FAMILY HISTORY NO

(Have any immediate family

YES

PRESENT SYMPTOMS 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?

Have you ever had your cholesterol measured?

YES

YES

NO

(Please list below)

Date:[mo/yr]

NO If yes, TC Value:

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? How much per day:

YES

NO

2 packs

When? [mo/yr]

How many years and how much did you smoke? Do you drink any alcoholic beverages? Beer

(cans)

Wine

(cups)

Tea

NO If Yes, How much in 1 week?

(glasses) Hard Liquor

Do you drink any caffeinated beverages? Coffee

YES

(glasses)

YES

(drinks) NO

Soft Drinks

If Yes, How much in 1 week? (cans)

ACTIVITY LEVEL EVALUATION What is your occupational activity level?

Sedentary

Light

Moderate

Do you currently engage in vigorous physical activity on a regular basis? If so, what type?

Heavy

YES

NO

How many days per week?

How much time per day?

45 min

Do you ever have an uncomfortable shortness of breath during exercise? Do you ever have chest discomfort during exercise?

YES

NO

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

On average:

NO

How often:

If so, what activities:

days/week

For how long?

Are you currently following a weight reduction diet plan? If so, how long have you been dieting?

months

minutes/session YES

NO

Is the plan prescribed by your doctor?

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:

YES

NO

Pre-Competition HOMEWORK!

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) Record Your Height: ___________ (inches)

Assessment 2:

Muscular Strength and Endurance

# of Push –Ups to Fatigue: ________ Females: Males: All:

Assessment 3:

* Your BMI will be calculated by Wellness Coord.

*Push-ups must be in a row without resting

Position hands under shoulders, and knees on ground Position hands under shoulders, and toes on ground (knees off ground) Keep spine in neutral/flat position throughout motion

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

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

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!

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 weighins) 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!

Starting Weight:

______

Current Weight:

Weight Loss to Date: ______ % Weight Loss:

_______

Weekly Weight Loss: _______

______

Physical Activity Cardio Minutes

Sun Mon Tue Wed Thurs Fri Sat 4-5 days ________ ________ ________ ________ ________ ________ ________

Strength Training

2-3 days















Stretching

7 days















Date:

____ Dairy

Dairy

Fruit Vegetables

Fruit

LUNCH

Grains

Grains Dairy

Protein

Vegetables Protein

Fruit

Sweets, Fats, Drinks 150 calories/box

Grains Vegetables

BREAKFAST

DINNER

Protein

Water

Date:

____ Dairy

Dairy

Fruit Vegetables

Fruit

LUNCH

Grains

Grains Dairy

Protein

Vegetables Protein

Fruit Grains Vegetables

BREAKFAST

Water

Protein

DINNER

Sweets, Fats, Drinks 150 calories/box

NAME ______________________________ Challenge:

WEEK 1 October 6-12 Sunday _______ _______ Fruit: _______ _______

Eat one fruit serving AND one vegetable serving at lunch AND dinner on five days of the week! Tuesday Wednesday Thursday Friday Saturday _______ _______ ______ ______ _______ _______ _______ ______ ______ _______ _______ _______ ______ ______ _______ _______ _______ ______ ______ _______

Monday _______ _______ _______ _______

Veg:

Challenge:

WEEK 2 October 13-19

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.

MONDAY

TUESDAY

Tuesday AM PM

Wednesday AM PM

Thursday AM PM

Friday AM PM

Challenge:

WEEK 4 October 27- Nov 2

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

Monday ________ ________

Tuesday ________ ________

Wednesday _________ _________

Thursday ________ ________

Friday Saturday ________ ________ ________ ________

Challenge:

WEEK 5 November 3-9 Monday

WEEK 6 November 10-16 Sunday Dish: _______

FRIDAY

Walk 15 minutes on at least 5 breaks this week.

Monday AM PM

Sunday

THURSDAY

Challenge:

WEEK 3 October 20-26

Sunday Mode: _______ Time: _______

WEDNESDAY

Tuesday

Incorporate 2 days of strength training to your exercise program. Wednesday Thursday Friday Saturday

Challenge: Include fish into 2 meals this week. Monday _______

Tuesday _______

Wednesday _________

Thursday ________

Friday Saturday ______ ________

Challenge: WEEK 7 November 17-23 Sunday Mode: _______ Time: _______

Exercise at least 4 days this week for 30+ minutes each day. Monday ________ ________

Tuesday ________ ________

Wednesday _________ _________

Thursday ________ ________

Friday Saturday ________ ________ ________ ________

WEEK 8 November 24-30

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

Sunday Veg: Veg: Fruit:

Monday

______ _______ ______ _______ ______ _______

_______ _______ _______ _______ _______ _______

Tuesday

Wednesday

Thursday

________ _______ ________ _______ ________ _______

_______ ______ _______ ______ _______ ______

______ _______ ______ _______ ______ _______

Complete the circuit challenge this week!

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Challenge:

WEEK 10 December 8-14

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

Monday

Tuesday

Wednesday

Thursday

Friday

Challenge:

WEEK 11 December 15-21 Sunday Mode: _______ Time: _______

Saturday ______ ______ ______ ______ ______ ______

Challenge:

WEEK 9 December 1-7 Sunday

Friday ______ ______ ______ ______ ______ ______

Exercise 30+ minutes on 5 days this week Monday ________ ________

Tuesday ________ ________

Thursday ________ ________

Friday Saturday ________ ________ ________ ________

Challenge:

WEEK 12 December 22-28 Sunday Monday _______ ________ _______ ________ _______ ________ WEEK 13 December 29- Jan 4

Wednesday _________ _________

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

Wednesday _________ _________ _________

Thursday ________ ________ ________

Friday ________ ________ ________

Saturday ________ ________ ________

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

FINAL WEIGH-IN – "[enter date]" ! WINNERS ANNOUNCED!