PACE Registration
PACE 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 PACE 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 PACE Program? __________________
What County are you in? __________________________________
What do you want this program to help you with?
□ Lose Weight □ Become more active
□ Eat Healthier □ Overall Health (all of these)
Signature: ____________________________________________
Date: ________________