Grant Funded Programs Application: WV Work It Out

*Required Fields

Date of Health Screen: (mm/dd/yyyy)*  

Date of Operating Plan: (mm/dd/yyyy)*  

Date of Last Lifestyle Change Program: (mm/dd/yyyy)*  

Name of Last Lifestyle Change Program:*  

Worksite Name:*  

Worksite Coordinator Name:*  

Mailing Address:*  

                                

City:*      State:*      Zip:*    

County:*  

Phone Number:*    

Fax Number:  

E-mail:  

Worksite ID Number:

Health Promotion Consultant:*  

Grant History:     New Applicant           Previous Grantee

Please select which option is preferred: Option 1    OR    Option 2

Option 1
  • 30 Minute Fitness Assessment at Worksite
  • Exercise physiologist will prepare a personalized exercise program for each participant and a copy of Yourself Fitness (computerized personal training) or other tools will be provided as appropriate for the participant’s specific fitness level. Participants having access to a worksite fitness facility will not receive a tool.

    A personal trainer will assist the individual with the implementation of their fitness plan if the worksite has a fitness facility.

OR

Option 2
  • 15 Minute Fitness Assessment at Worksite
  • Exercise class with a credentialed instructor will then be made available after the initial fitness assessments have been completed.
  • Classes will meet once weekly for 8 weeks at the worksite.
  • Limit of 15 people per worksite
  • A minimum weekly attendance of 5 individuals per exercise class is required