DREAM Registration

DREAM Program

Mid-Ohio Valley Health Department

211 Sixth Street

Parkersburg, WV 26101

Program Registration Form

Name: __________________________________________________

DOB: ___________________________________________________

Address: _________________________________________________

Phone Number: ___________________________________________

E-Mail: __________________________________________________

Emergency Contact Name: _______________________________________

Emergency Contact Number: ______________________________________

Time Preference for monthly DREAM appointment:

Early Morning: 6 am -8 am Daytime: 8 am – 4pm

Early Evening: 4 pm -6 pm Saturday: 9 am – 1 pm

How did you hear about the DREAM Program? __________________

Do you Smoke? □ yes □ no What County are you in: _________________

What do you want this program to help you with?

□ Weight Management □ Become more active

□ Eat Healthier □ Overall Health (all of these)

Signature: __________________________________________

Date: __________________