Name: _________________________________________

Date of Birth: _______________

Address: _________________________________________

Phone Number: _______________

At Home Kit #: _______________

Min No Aya Win OR Center for American Indian Resources (circle one)

The 12:00 OR 4:45 (circle one) meeting time best fits my schedule

Native American    OR    Non-Native American (circle one)

I realize that by signing this consent form I will be enrolled in Weight Watchers® At Home through Fond du Lac Human Services. I understand this program is designed to help me lose weight by making healthy lifestyle changes. The Diabetes program provides one At Home Kit to eligible participants. If any portion of my kit is lost or damaged, it will not be replaced by the Diabetes Program. If I’m not eligible for a free At Home Kit, I will complete an order form with personal payment that will be sent to Weight Watchers. I will participate in weekly meetings for weighing in, support and education. I will discuss my participation in this program with my medical provider.

I have read this consent form. I understand its contents, and I agree to participate in Weight Watchers® At Home under the conditions described.

Participant’s Signature: _________________________ Date: _______________