Sign Up Forms
To get started:
1. Complete the Registration Form immediately
and drop it off at the YMCA or send it to us
according to the instructions on the form.
2. Have your medical professional complete and
sign the Safe Exercise Assessment Form.
3. Sign the Safe Exercise Assessment Form yourself
and return it according to the instructions on
Phone # __________________________________
Language ______ English _______ Spanish
Which location will you use? ________________
Check your preferred method of communication:
Please return this form in one of these ways:
1. Drop it off at the YMCA
2. Email to firstname.lastname@example.org
3. Fax to Challenge Diabetes, Att: Coordinator 413-567-5734
4. Mail to Challenge Diabetes, P.O. Box 4655, Springfield, MA 01101
Safe Exercise Assessment Form
To be completed by your medical professional:
Which type of diabetes does this patient have? Type 1 ___ Type 2 ___
Does this patient take medications that may cause a very low blood glucose level? ___ ___
If yes, does he/she know the symptoms and treatment of low blood glucose? ___ ___
Does the patient have exercise limitations that a personal trainer should know about? ___ ___
If yes, please explain:
To evaluate how effective the program has been we will compare the participant's last A1c before beginning
to the first one after. the medical professional and participant both agree to provide your first A1c after completion of the program for this purpose.
Patient's last A1c result ________ Date of test ____________
______________________________ ________________________________ ____________
Medical Professional's Signature Medical Professional's Printed Name Date
______________________________ ______________________________ ____________
Paticipant's Signature Participant's Printed Name Date
This form contains confidential information that must be returned on one of these ways:
Email it to email@example.com
Fax it to Challenge Diabetes, Att: Coordinator 413-567-5734
Mail it t: Challenge Diabetes, P.O. Box 4655 Springfield, MA 01101 Att: Coordinator
Participant may bring forms to any training session.
Do not drop it off or mail it to the YMCA
ChaType your paragraph here.