(Please be specific when filling out this form)

Fill out and send as attachment to "info@yforme.org" 

or you can mail it to us at:
YOFF, 3261 Marydon Dr, Baton Rouge, La. 70814
Or email at info@yforme.org

To contact us: 225-571-5186 or email to info@yforme.org

Name: ________________________________________________________


Home phone number: ____________________________________________

Age: ______

Date of birth: ___________________________

Height: _____


School: _______________________________________________________

Father’s name: __________________________________________________

Fathers Employer: _______________________________________________

Address of Employer: ____________________________________________

Work number: __________________________________________________

Mother’s name: _________________________________________________

Mothers Employer: ______________________________________________

Address of Employer: ____________________________________________

Work number: __________________________________________________

Name of your primary physician: ___________________________________

Do you have health insurance: _______?

Are you currently on any weight loss medication: ___Yes    ___No?

Have you ever had a physical: _____ if yes, when was your last physical ______________________?

Name of Doctor who performed your last physical: _______________________________________

Are you currently on medication: _____  If yes, please list them and why: 

Have you ever broken or fractured a bone? _____   If yes, list them in order of 


Have you ever had surgery because of being over weight? _____ If yes, list procedure and date of operation 

Have you been diagnosed as ADD, or ADHD? _____ If yes, list any medication you are on: 

Have you ever participated in athletics? ____ If yes, list sport(s) and name of school or team: 

Please write a brief comment on why you want to join in the YOFF program and what are your goals for your health: (ex. How much weight do you want to loose? How willing are you to reach your goals?)