Shape Up

A Lifestyle Modification Program

Program Dates: August 24th – November 10th2017
Application Deadline:MondayAugust 14th, 2016 by 5:00 p.m.

Introduction

Shape Up is an 12 week program designed for individuals who are not currently exercising, or do not workout very often. This program is structured and designed under the guidance of an exercise physiologist. The goal of the program is to engage participants in regular bouts of exercise, as well as help develop and maintain a healthy lifestyle. The program is comprised of 12 total weeks with week 1 and 12 devoted to pre and post assessments(blood pressure, height, weight, body mass index, circumference measurements,flexibility and a cardiovascular fitness test).

This program is limited to twenty (20) OSU-Stillwater benefits-enrolled employees who have not previously participated in the Shape Up Program. Participants must be available August 24th – November 17th and agree to attend both the initial and post assessments, as well as 15 of the 20 sessions (75%), finally, the participants must turn in a weekly physical activity log during weeks 2-11 of the program. Failure to comply with the aforementioned criteria will result in a charge to your Bursar account in the amount of $100.

Program includes incentives which are subject to taxation.At the conclusion of the program, OSU Payroll Services will be notified of the retail value of incentives received.

Eligibility Requirements:

  1. If selected as a participant for the program you must execute all waivers and releases required by the Department of Wellness.
  2. You must be available for the entire 12 week duration of the program. You must attend both the pre and post assessments, as well as 75% of the workouts and turn in weekly exercise logs.
  3. You must be willing to attain physician’s clearance if needed.
  4. Selection is based upon a questionnaire that defines you as not performing more than 3 hours of structured cardiovascular exercise a week, nor weight training more than once a week.
  5. This program is limited to OSU-Stillwater benefits-enrolled employees that have not previously participated in the Shape Up Program, and those who do not currently have a musculoskeletal injury that has been diagnosed in the past 6 months.
  6. This is not a scientific study and selections are final.

Meeting Dates & Times:

Pre-Test (Week 1) (August 24th – September 1st)Assessment will take about 1 hour, you can sign up for your appoint during the times of 6:00-10:30 am

Group Workouts (weeks 2-11):(September 4th – November 10th 2017).

Workouts will be every Monday/Wednesday, you choose which time you would like to workout. The times are from 6:00-6:45 am, 12:15-1 pm, or 5:15-6:00 pm6:00-7:00 am, 12-1 pm, or 5:30-6:30 pm.

Post-Test (Week 12) (November 13 – November 17)Assessment will take about 1 hour, you can sign up for your appoint during the times of 6:00-10:30 am

Application

Section I: Personal Information

First Name / Middle Name / Last Name
Home Street Address
City / State / Zip Code
Phone (work) / Phone (home) / Phone (cell)
E-mail Address / CWID
Age (as of today) / Date of Birth / Gender(check one)
_____Male ______Female
Height / Weight
OSU Department / Job Title / Normal Working Hours

Section II: Health and Fitness Goals

What are your health and fitness goals, and what is your timeline of wanting to achieve these goals?
Short term (1-4 week)
Long term (12+ weeks)
What is the timeline you are wanting to achieve your short term and long term goals?
(I.e., by the 6th week of the program I want to be able to run for 5 minutes straight at a speed of 5.5 mph)

Please rate each component of health and fitness listed below. Check the box that best

describes how important each one is to you at this time

Most Important / Very Important / Somewhat Important / Not Very Important
Blood Pressure Control
Cardiovascular Fitness
Improved Flexibility
Muscular Strength
Relaxation Techniques
Stress Management
Time Management
Weight Management

Current Exercise Status (Please answer all questions based upon your current exercise routine)

Do you regularly engage in cardiovascular exercise (walking, jogging, running)? Yes No

How many days per week do you perform this type of exercise? ______

How many hours per week do you perform this type of exercise? ______hours

Do you regularly engage in strength training exercises (body weight, machines, classes)? Yes No

How many days per week do you perform this type of exercise? ______

How many hours per week do you lift weights? ______hours

Consents and Releases

I hereby acknowledge that : (i) I have answered the previous questions honestly and accurately; (ii) I will immediately inform the Department of Wellness (the “Department”) if any information I have provided becomes false or incomplete; (iii) if any of the above information is found to be false or incomplete this will be grounds for dismissal from the participant selection process, and/or from the Shape Up program (the “program”), if selected; (iv) even if I meet the above eligibility requirements, the Department has no obligation to select me as a participant. I further understand that the program is limited to twenty(20) participants; (v) even if I am selected as a participant, the Department has no obligation to conduct the program; (vi) all decisions by the Department concerning selection of participants are final and not subject to challenge or appeal; and (vii) the Department has no obligation to return any material submitted by me as part of the application whether or not I am selected as a participant.

I understand that the program involves physical activity.

I acknowledge that before participating in the program, I will consult with my own physician regarding the advisability from a physical and emotional health perspective of my potential participation in the program. I represent that if I proceed with the participant selection process and am selected to be a participant in the program, I know of no reason, following consultation with my own physician, why I should not participate in the program.

I agree to release, defend, indemnify and hold harmless the Department and its employees, agents, officers and directors from and against any and all claims, actions, lawsuits, liabilities and expenses arising from or relating to my participation in the program including, without limitation, the participant selection process.

COMPLIANCE:Compliance, for the purposes of this agreement is defined as participating in each component listed below. (Please initial each section to indicate you have read and understand the conditions listed.)

______ASSESSMENTS:I agree to complete a health assessment during Week 1and Week 12 of the program.

______PHYSICAL ACTIVITY: I agree to participate in 75% (at least 15 of the 20 sessions) of the organized workouts provided by the Department of Wellness. I also agree toturn in a weekly physical activity log during 9 weeks of the program.

______SELECTION:If I am selected, I understand I can decline participation prior to start of program.

Cancellation Policy: A 24-hour notice is required for cancellation of group training sessions, or there will be a $15.00 missed appointment fee. Cancellations must be made during normal business hours and are accepted by phone only at 405-744-8743.

I give permission for the Department of Wellness to email my personal results from the program at any time.

I understand that if I am not compliant with the program (as outlined above) my bursar account will be charged the amount of $100.00 and I agree to pay the said amount.

I further understand that if I do not meet the aforementioned program requirements (stated compliance portion outlined above), I will not be eligible to apply for and/or participate in the following Specialty Programs:

  • Choose You
  • Cowboy Challenge
  • Shape Up

I have read, understand, and agree with the foregoing.

Signature ______

Print Name______

Date______Preferred email address: ______

Applications will only be considered if they are completed. The application deadline is Monday August 14th by 5:00 p.m., or until filled. Applicants will be contacted no later than Wednesday August 16th, 2017 by 5 pm.

You may submit your application online, or send you completed application to Eric Conchola, Fitness Specialist, through one of the following means: Campus Mail: 005AESeretean Wellness Center; Fax: 744-7670; or EMAIL:

Thank you for your time and effort in completing this application.