First Name  * required Last Name  * required Mailing Address  * required City  * required State  * required Zip Code  * required Phone (XXX-XXX-XXXX)  * required Email Address  * required Emergency Contact (Name and Phone Number) I agree to support the Barix Guidelines: Limiting added sugars to 2 grams/serving. Limiting fat intake. Regular exercise. Vitamin supplementation guidelines. Attending follow-up appointments. I have reviewed the positon description and agreement and am able to fulfill the responsibilities as outlined: Yes No I have adequate time to commit to this position: Yes No Unsure

Do you currently or have you in the past attended a Barix Support Group? location of support group/group leader's name/positive experiences/negative experiences List leadership positions that you have held: List ideas that you would like to bring to your support group: How has bariatric surgery changed your life: Do you personally follow Barix recommendations? Are you at a healthy weight?