On site Exercice Program Incentive Program Request for Net

							                   On-site Exercice Program
                   2008 Incentive Program
                 Request for $25 Net Incentive

Exercise program must have been completed after 11/01/07 and prior to
10/31/08. Date(s) incentive is to be distributed 01/30/08; 06/30/08 or
11/30/08. Please see the 2008 Incentive Program rules for further
information. Program deadline dates for submission of paperwork:
12/15/07; 05/31/08 OR 10/31/08.

Requirements for On-site Exercise Program:

   1. Must either participate or lead in a worksite exercise program or class.
      (Examples: start a walking, running, or aerobics group. Recruit an
      exercise partner to work out, run, or walk with you twice a week.
      Participate in various on-site exercise/fitness classes such as boot
      camp, pilates, etc.).

   2. If participating in a class, register for class via TRAC, or if you
      do not have TRAC please call Angela Gustafson 650-9908.

   3. Must complete the Pre-Exercise Survey. (See attached)

   4. Please note that exercise attire (sneakers, flexible apparel, and
      towel) is necessary for all classes and some facilities may or
      may not have showers. Classes are subject to cancellation;
      however we will try to notify you in advance. If you have special
      needs/concerns, please contact the Instructor ahead of time.

   5. Exercisers must meet at least once a week for 6-8 weeks and
      complete the Exercise Log (see attached) to be turned in upon
      completion. Please note that participating in the Pedometer Program
      cannot be applied to this program congruently but rather sequentially.

   6. Complete the Post Exercise Survey (see attached) after completing
      6-8 weeks of exercise. All forms must be submitted in order to
      receive incentive.

                        Send completed forms to:
          Angela Deem-Gustafson, Wellness Development Advisor
           1660 Ringling Blvd, 4th Fl Employee Health & Benefits
                            Sarasota, Fl 34236
           T 941-650-9908, F. 941-861-5825 adeem@scgov.net
                        Pre-Exercise Survey
                          On-site Exercise
                      2008 Incentive Program

Name: ____________________Date of Birth: __ __/__ __/__ __
Last 4 Digits of Social Security Number: __ __ __ __
Phone Number: _______________Email address: _____________________
Work Location: ____________________________________
  1. What is your motivation for participating in an on-site exercise
     program (ex. weight loss, increase physical activity level, improve
     health & fitness, relieve stress, etc.)?


  2. What fitness or health goals do you have for yourself?



  3. Besides increasing your daily physical activity, what other actions
     can you do to help yourself reach these goals? (ex. eating healthy,
     make time for myself, ask for family support, etc.)



  4. What do you foresee as potential obstacles to increasing your
     physical activity?



  5. List some actions or ways that can help you overcome these
     potential obstacles?



  6. How do you think you will feel after achieving your goals? (ex. more
     energy, more resistant to stress, improved physical fitness, etc.)




                   Please submit completed form to:
           Angela Deem-Gustafson, Wellness Development Advisor
          1660 Ringling Blvd, 4th Fl Employee Health & Benefits
                           Sarasota, Fl 34236
                  T 941-650-9908, F. 941-861-5825
                           adeem@scgov.net
                                   Exercise Log
           (Please complete weekly and turn in at the end of the 6-8 weeks)

   Name: ________________Class Participated in (if applicable):______________

   Each day that you exercise or you participate in an on-site exercise class, please
   mark in the box the type of activity/exercise and the number of minutes, miles or
   sets completed. See example below

                        SAMPLE : Date Beginning: 01/03/08
Monday    Tuesday     Wednesday Thursday Friday      Saturday          Sunday        Total
                                                                                   3m Run
 Run 3                   Walk        Weight                                        2m Walk
 miles                   2           lift for 30                                   30min Lift
                         miles       min




                     Week One: Date Beginning:____________
Monday   Tuesday     Wednesday Thursday Friday      Saturday           Sunday     Total




                     Week Two: Date Beginning:____________
Monday   Tuesday     Wednesday Thursday Friday      Saturday           Sunday      Total




                     Week Three: Date Beginning:____________
Monday   Tuesday     Wednesday Thursday Friday        Saturday         Sunday      Total




                      Week Four: Date Beginning:____________
Monday    Tuesday     Wednesday Thursday Friday       Saturday         Sunday     Total
                    Week Five: Date Beginning:____________
Monday   Tuesday    Wednesday Thursday Friday        Saturday        Sunday         Total




                     Week Six: Date Beginning:____________
Monday   Tuesday     Wednesday Thursday Friday       Saturday         Sunday        Total




                 Week Seven: Date Beginning:____________
Monday   Tuesday Wednesday Thursday Friday        Saturday           Sunday         Total




                    Week Eight: Date Beginning:____________
Monday   Tuesday    Wednesday Thursday Friday        Saturday        Sunday         Total




                         Send completed exercise log to:
                 Angela Deem, RN, Wellness Development Advisor
                            1660 Ringling Blvd. 4th Fl
                               Sarasota, Fl 34236
                        T. 941-650-9908, F 941-861-5825
                               adeem@scgov.net



  Name: ____________________                     Date of Birth: __ __/__ __/__ __

  Last 4 Digits of Social Security Number: __ __ __ __

  Phone Number: ________________                 Email address: ___________

  Work Location: ____________________________
                         Post-Exercise Survey
                           On-Site Exercise
                        2008 Incentive Program

Name: ____________________Date of Birth: __ __/__ __/__ __
Last 4 Digits of Social Security Number: __ __ __ __
Phone Number: ___________Email address: ______________________
Work Location/Address: ____________________


   1. Were you able to increase your physical activity from your starting
      point by taking this class? Yes / No
         If Yes, by how much (Ex., more days/week; more minutes/work-
         out, etc):______________________________________________
         If No, what do you feel kept you from increasing your activity:
         ______________________________________________________
         ______________________________________________________

   2. How did you benefit from this program?




   3. Do you plan to continue to exercise after having completed this
      program?



   4. What were you most surprised to learn about your physical activity
      after completing this program (ex. How little daily exercise you
      actually got, how recording your “work-outs” made you more
      committed to continuing, how much better you felt after working out,
      etc.)


   5. Please circle the program(s) you completed:
         a. Boot Camp
         b. Deniese’s Class (Exercise Fusion)
         c. Gina’s Class (Pilates & More, Spice It Up, etc.)
         d. Intern Class
         e. Other:____________________________________

                  Please submit completed form to:
       Angela Deem-Gustafson, RN, Wellness Development Specialist
           1660 Ringling Blvd, 4th Fl Employee Health & Benefits
                            Sarasota, Fl 34236
          T 941-650-9908, F. 941-861-5825 adeem@scgov.net