Faculty and Staff Guide to Wellness - FALL 2012 FIT Zone Classes Registration Survey

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1. First Name

First Name

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2. Last Name

Last Name

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3. Are you a member of UCLA Recreation?

Are you a member of UCLA Recreation? No

Yes

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4. Department

Department

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5. Email

Email

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6. Please indicate Staff, Faculty, or Other

Please indicate Staff, Faculty, or Other

FIT Zone - Workouts for work breaks! These workouts are located close to where you work and are FREE for all UCLA Staff & Faculty. Sign-up, drop-in, and get active! These classes are designed to help UCLA Staff & Faculty manage stress; increase mental clarity and productivity; get fit, stay fit, and be well!

7. MAT PILATES (Beginning/Intermediate)

MAT PILATES (Beginning/Intermediate) Tu, Th 12:30pm-1:20pm, Wilshire Center Ste. 107

F, 12:05pm-12:55pm, UNEX Rm 714 and W,F 1:05pm-1:55pm,

8. HULA HOOP WORKOUT- Beginning/Intermediate

HULA HOOP WORKOUT- Beginning/Intermediate M, W 12:15-12:45pm, Inverted Fountain

T, Th 11:45am-12:15pm, Janss Steps

9. ZUMBA WORKOUT- (Beginner Friendly)

ZUMBA WORKOUT- (Beginner Friendly) M, 12:10-12:50pm, NPI Auditorium

T, Th 12:10-12:50pm, Kaufman Hall Room TBD *(WAC Staff and Faculty Priority/Limited Space)

T, 5:15-6:15pm, Wilshire Center Ste. 107, Fri, 11:30-12:20pm, Wilshire Center Ste. 107

W, F 12:10-12:50pm, Engineering IV Patio

W, 12:10-12:55pm UNEX Rm 714

Tu, 2:30-3:30pm Sproul Hall, Th, 3:30-4:40pm De Neve TBD

I am planning to attend at multiple locations

Enter an answer

10. TAI CHI

TAI CHI M, 12:05pm-12:55pm, UNEX Rm 714

Tu, 12:35pm-1:35pm, Inverted Fountain

Th, 12:00pm-1:00pm, Corner of Le Conte and Westwood

F, 12:15pm - 1:15pm, Wilshire Center Ste. 107

11. TOTAL BODY WORKOUT Level 1/2

TOTAL BODY WORKOUT Level 1/2 Tu,Th 11:30-12:20pm, Wilshire Center Ste. 107, Th, 5:15-6:15pm, Wilshire Center Ste. 107

Tu, Th 12:15-12:50pm, Meet @ Bottom Janss Steps

M, W,F 12:10-12:50pm, Meet @ Dickson Court South next to Schoenberg Hall

Tu, Th 12:10-12:50 CHS Room 71-257

12. YOGA

YOGA M,W 11:00am-12:00pm, Beginner Yoga, Wilshire Center Ste. 107, Brenda

M,W 12:10pm-1:10pm, Level 1/2, WIlshire Center Ste. 107, Brenda

M,W12:00-1:00pm, Level 1/2, Perloff Hall Rm 1302 De Cafe, Margeaux

Tu, Th 12:05pm-12:55pm and 1:05pm - 1:55pm , Level 1/2, UNEX Rm 714, Dearbhla

Tu, Th 12:00-1:00pm, Level 1/2, MOL SCI Rm. 3440 Brenda

Tu, Th 12:00pm-1:00pm, Level 1/2, Boelter 8500 PH, Joan

W, 5:10-6:10pm, Level 1/2, UNEX Rm 714, Andrea

M, 5:15-6:15pm, Level 1/2, Hammer Museum 3rd Floor Video Gallery, TBD

PRE/POST NATAL, F, 12:00-1:15pm, Dynasty Room @ JWC, *Need to bring Doctor's clearance to your first class

I am attending at Multiple Locations

13. MEDITATION (Might not be happening...stay tuned.)

MEDITATION (Might not be happening...stay tuned.) Tu, 7am-8am, Wilshire Center Suite 107

14. WET WORKOUT

WET WORKOUT M-F, 12:10-1:10pm, Family Pool, Sunset Canyon Recreation Center (ALL DAYS)

M, 12:10-1:10pm, Family Pool, Sunset Canyon Recreation Center

T, 12:10-1:10pm, Family Pool, Sunset Canyon Recreation Center

W, 12:10-1:10pm, Family Pool, Sunset Canyon Recreation Center

Th, 12:10-1:10pm, Family Pool, Sunset Canyon Recreation Center

Fri, 12:10-1:10pm, Family Pool, Sunset Canyon Recreation Center

15. WEEKLY WALKS (Suggested Meeting Spots, No Instructor)

WEEKLY WALKS (Suggested Meeting Spots, No Instructor) MW, 11:30-12:30p, Westwood Blvd. in front of Ronald Reagan Center

MW, 12:00-1:00pm, Tiverton Roundabout outside Marion Davies Children’s Clinic

TuTh, 12:00-1:00pm, Front of Kinross

TuTh, 12:00-1:00p, SE corner of Westwood Blvd. & Charles E. Young

W, 12:10pm-12:50pm, Inverted Fountain

FIT Sports: Use drop-in sports to get active and enjoy the camaraderie of your colleagues with FREE Lunch Time Leagues. Drop-in for a game or form a department team if you want! Either way, it's easy . . . just show up at the gym with your UCLA ID and play!

16. *Basketball (Coed 5 v. 5)(select all that apply)

*Basketball (Coed 5 v. 5)(select all that apply) MW, 11:45 am-1:00 pm, SAC (Student Activities Center)

17. Soccer (Coed)(select all that apply)

Soccer (Coed)(select all that apply) TuTh, 11:45am-1:00 pm, IM Fields or North Athletic Field Depending

Question 15-19 are optional, however these questions are geared toward collecting data that will help to develop and improve FITWELL Programs for Faculty and Staff. Responses are confidential and will not be shared.

18. How would you rate your present energy level at work?

Very Low	Low	Medium	High	Very High
*How would you rate your present energy level at work? Very Low	Low	Medium	High	Very High

19. How would you rate your ability to cope with daily stress at work?

Very Low	Low	Medium	High	Very High
*How would you rate your ability to cope with daily stress at work? Very Low	Low	Medium	High	Very High

20. How do you feel about your present physical condition in terms of overall health?

Very Dissatisfied	Dissatisfied	Somewhat Satisfied	Satisfied	Very Satisfied
*How do you feel about your present physical condition in terms of overall health? Very Dissatisfied	Dissatisfied	Somewhat Satisfied	Satisfied	Very Satisfied

21. In which of the following categories would you place yourself?

In which of the following categories would you place yourself? I am aware that physical activity will improve my heath, but I am disinterested.

I am interested in becoming more physically active to improve my health, but I am not currently physically active.

I am interested in becoming more physically active to improve my health, and I plan to start exercising in the near future.

I have recently become more physically active.

I have been physically active for less than 6 month.

I have been physically active for more than 6 months.

22. How many times per week do you engage in physical activity? (Physical Activity= 30 min. or more of gardening, biking walking exercise class, etc.)

How many times per week do you engage in physical activity? (Physical Activity= 30 min. or more of gardening, biking walking exercise class, etc.) I am not currently physically active.

1-2 times per week

3-4 times per week

5 or more times per week

In order to complete your registration, Please read the following waiver (CLICK HERE) and indicate below you have read and understood this document.

*

23. I understand by agreeing, my signature is being transferred electronically, and I will not challenge the validity of the signature in any legal proceeding in which this document may be offered or used.

I understand by agreeing, my signature is being transferred electronically, and I will not challenge the validity of the signature in any legal proceeding in which this document may be offered or used. Yes

No