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Please fill out the following information to sign up as a registered member
of the Maine in Motion program. Included in membership is a personal fitness
calendar to track your physical activity, information, and other
journal notes.
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Are you signing up as
an individual
or as the head of a
family or classroom? |
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Signup as |
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(if you are the coordinator of
a worksite group and would like to receive stats on
participants at your location, please contact
dianec@mcd.org with your request. Please make sure your
participants enter a worksite name in the "other" category
if it is not listed in the pull down.) |
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Registration
(*=required) |
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First Name* |
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Last Name* |
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Gender |
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Email |
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Password* |
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(6
characters or more please) |
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Retype Password* |
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Date of Birth* |
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Address* |
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Address (cont.) |
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County |
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City* |
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State* |
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ZIP* |
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Phone |
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()
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Fax |
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()
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Height |
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ft.
inches
(without shoes) |
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Weight |
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lbs.
(without shoes) |
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Preferred tracking |
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If you are a
student... |
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Your grade level |
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Your school |
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Other |
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(if your school is not listed) |
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If you are NOT a
student... |
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Primary Employment |
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Your work site |
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(if you are the coordinator of a
worksite group and would like to receive stats on participants
at your location, please contact
dianec@mcd.org with your request. Please make sure your
participants enter a worksite name in the "other" category if it
is not listed in the pull down.)
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Other |
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(if
your work site is not listed) |
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Branch |
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Educational Level |
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Please
answer some questions about yourself and your activity level.
Regular physical
activity is defined as achieving at least:
-30 minutes (in bouts of at least 10 minutes at a time) of moderate-
intensity activity on 5 or more days of the week OR
-20 minutes of vigorous-intensity activity on 3 or more days of the
week. |
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What
best describes your current level of exercise? |
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I do not participate in regular physical activity now, but intend to
in the next 30 days. |
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I do not participate in regular physical activity now, but intend to
in the next 6 months. |
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I do participate in regular physical activity now, but have been for
less than 6 months. |
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I have been participating in regular physical activity for more
than 6 months. |
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Moderate physical activities are those in which a
person would experience some increase in breathing or heart rate.
Examples of moderate physical activities include walking, cycling,
dancing, gardening and yardwork, and various domestic and
occupational activities.
Vigorous physical activities are those in which a
person would experience a large increase in breathing or heart rate.
Examples of vigorous activities include jogging/running, lap
swimming, cycling, skating, cross-country skiing,
hiking/backpacking, racquet sports, and competitive group sports
(soccer, basketball, etc.).
If you DO
currently participate in regular physical activity: |
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1. Choose an activity... |
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activity
other
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level
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days
per week
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minutes per day
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2.
Choose another activity... |
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activity
other
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level
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days
per week
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minutes per day
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3.
And a third activity... |
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activity
other
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level
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days
per week
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minutes per day
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4. How
many Tours of Maine do you expect to complete? (What
are Tours?) |
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(you can start and end tours at any time) |
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Common
sense is your best guide when you answer these questions. Please
read the questions carefully and answer each one honestly to
yourself. |
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5. Has
your doctor ever said that you have a heart condition and that you
should only do physical activity recommended by a doctor? |
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6. Do
you feel pain in your chest when you do physical activity? |
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7. In
the past month, have you had chest pain when you were not doing
physical activity? |
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8. Do
you lose your balance because of dizziness or do you ever lose
consciousness? |
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9. Do
you have a bone or joint problem (for example: back, knee, or hip)
that could be made worse by a change in your physical activity? |
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10. Is
you doctor currently prescribing drugs (for example: water pills)
for your blood pressure or heart condition? |
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11. Do
you know of any other reason why you should not do physical
activity? |
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If you
answered: |
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YES
to one or more questions |
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NO
to all questions |
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Talk with your doctor by phone
or in person BEFORE you start becoming much more physically
active. Tell your doctor about the above questions and which
questions you answered YES.
You may be able to do any activity you want: as long as you
start slowly and build up gradually. Or, you may need to
restrict your activities to those which are safe for you.
Talk with your doctor about the kinds of activities you wish
to participate in and follow his/her advice. |
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If you answered NO
honestly to all questions, you can be reasonably sure
that you can start becoming much more physically active-
begin slowly and build up gradually. This is the safest and
easiest way to go.
You should delay becoming much more active if:
1. You are not feeling well because of a temporary illness
such as a cold or fever: wait until you feel better.
2. You are or may be pregnant: talk to your doctor before you
start becoming more physically active. |
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Informed use of the Par-Q: The Canadian Society of Exercise
Physiology, Health Canada, and their agents assume no liability for
persons who undertake physical activity, and if in doubt after
completing questionnaire, consult your doctor prior to physical
activity. |
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I
have read and understood the PAR-Q questions listed on this page.
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Choose
one of the following Governor's Challenges (these numbers will be set as your
goals on your personal calendar): |
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Bronze
Challenge (4 days activity per week) |
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Track steps- Goal:
8000 steps per day, 32000 steps per week
Track time- Goal: 30 minutes per day, 120 minutes per week |
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Silver Challenge
(5 days activity per week) |
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Track steps- Goal:
10000 steps per day, 50000 steps per week
Track time- Goal: 40 minutes per day, 200 minutes per week |
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Gold Challenge
(6 days activity per week) |
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Track steps- Goal: 12000 steps per day,
72000 steps per week
Track time- Goal: 50 minutes per day, 300 minutes per week |
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No Challenge |
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I would prefer to just
use the fitness calendar and not participate in any of the
Governor's Challenges. However, I understand that I can add a
challenge in the future at any time. |
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The following is
required. Please check the box to the left confirming that you
understand the information provided below. You must also type your
name into the box that says "My Signature". |
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I understand
that any information that I provide is privileged and confidential.
I agree to the use of information for evaluation and research
purposes as long as I am not identified. I have read,
understood, and completed the questionnaire. The Maine Governor's
Council on Physical Activity and their
agents assume no liability for persons who undertake physical
activity and hereby state that I am voluntarily participating in the
Maine in Motion program. My photo may be used for promotional
purposes. |
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My Signature
or
Parent/Guardian's signature if under age 18 |
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Yes, I would like to
receive a newsletter from Maine in Motion.
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Yes, I would like to
receive email reminders for upcoming events.
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Yes, I would like to
receive regular friendly email reminders from the Maine in Motion community.
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Yes, I would like to
receive reminders when my personal fitness activity calendar has
been inactive. |
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Yes, I would like to
receive notice when new surveys become available. |
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