Your Name:
Your Email Address:
Acknowledgement:	I certify that the data supplied in this update/submission is accurate to the best of my knowledge. Yes No

Program Name:
Street Address:
City:	,	NC	Zip:	-
County:	AlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMcDowellMaconMadisonMartinMecklenburgMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanlyStokesSurrySwainTransylvaniaTyrrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYancey	Phone:	()--

Program Sponsor Name:
Program Sponsor Title:

Multi-Site Program?:

Yes No

Website URL:

Years in operation:

Less than one year 1-3 years 4-10 years Greater than 10 years

Service

Part of program?

Available at additional fee?

Qualifications of individuals providing this service (select all that apply)

Registered Dietician

Exercise physiologist

Certified personal trainer

Written materials only

Clinical psychologist or trained behavior therapist

Health Educator

Nurse (RN, LPN)

Internal training program

Successful client

Other

One–on–one counseling

Yes No

Yes No

Group instruction or support

Yes No

Yes No

Weigh-ins

Yes No

Yes No

Fitness/exercise (beyond educational materials)

Yes No

Yes No

Personal Training

Yes No

Yes No

Behavior Modification

Yes No

Yes No

Healthy cooking instruction

Yes No

Yes No

Maintenance program once weight loss achieved

Yes No

Yes No

Support Group

Yes No

Yes No

Pre-program medical/clinical assessment

Yes No

Yes No

Is this a live-in program?:

Yes No

Type of Eating Plan(s) Offered (select all that apply)

Balanced reduced calorie Very low calorie (800 calories per day or less) Low carbohydrate Low fat/very low fat Other:

Does the program offer pre-packed food, meal replacements or supplements?:	Yes No
If yes, are clients required to buy pre-packaged foods, meal replacements or supplements?:	Yes No

	Program Duration	Meeting Frequency
Weight Loss:	Six weeks or less Two-four months Duration based on individual needs Other:	Daily or several times per week Once per week Two to three times per month Once per month Based on individual needs Other:
Maintenance:	Not Offered Six weeks or less Two-four months Duration based on individual needs Other:	Daily or several times per week Once per week Two to three times per month Once per month Based on individual needs Quarterly Other:

Is the program certified by the North Carolina Board of Dietetics/Nutrition?:	Yes No
Is the program owned and/or operated by a registered dietician?:	Yes No
If you are certified, what is the certification date?:

PROGRAM COSTS (please use average costs for core program for the following sections):
One Time Enrollment Fees	Average Weight Loss Phase (excluding food)	Required Foods (per week)	Maintenance Phase
Not applicable Less than $50 $50 to $200 $200 to $500 More than $500 Information not provided	Less than $50 $50 to $200 $200 to $500 More than $500 Information not provided	Not applicable Less than $50 $50 to $200 $200 to $500 More than $500 Information not provided	Not applicable No Charge Less than $50 $50 to $200 $200 to $500 More than $500 Information not provided

ENROLLMENT PROCESS:

When can individuals begin the program? Anytime Only when new classes/sessions are starting Other: Pre-enrollment Requirements: None Medical assessment or physical by clients own doctor or by the program Completion of a health assessment or health history Clients with the following conditions can participate in the program (select all that apply): Pregnancy Breast Feeding Cardiac condition Diabetes Medical Release Required for participation Ages of Clients Accepted into the Program (select all that apply) 12 years and under 13 - 17 18 and Older Families – both parents/guardians and children

Was a signature to release program information via the Authorization & Release document faxed or mailed?:	Yes No This form must be received by NCAHC before your program can be added to the Weight Management Registry
Notes (max length 255 chars):

Last date that data was entered: