To Register:

1. Fill out the following form.
2. When you get to the team section, either choose a team that is already created, or create your own team.
3. You are no longer required to print and bring in your registration form. You will only need to come to Hartshorn if you need to pick up your pedometer.
4. Start tracking steps, and have fun!!

*First Name:

*Last Name:

*Phone Number:

*Username:

(If you are concerned about privacy feel free to make up a username that doesn't reflect your real name.)

*Password

*Re-enter Password:

*Birthdate:

1 2 3 4 5 6 7 8 9 10 11 12 / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944

*Email Address:

*Local Address:

*City:

*Work Phone:

*Zip:

*Team:

Individuals L-WORD Key 2 SAHE Cohort 2 pizza SAHE Cohort 1 Braiden Hall SAHE 1st Years Rock! Allison Hall Plum Street Feat D1 Corbett The Shady Ladies ASAP walking awesome teamAH walk4fun Team Beefcake Newsom Westfall Walkers! walkie talkies Otters Edwards Hall Maisis AVB West Team Super Walkers bananas

If your team is not listed you can start it now.

Create a new team

Team Name:

Year in school:

1 2 3 4 5+ Grad

Sex:

Male Female

Ethnicity:

Caucasian African American Hispanic/Latino Asian or Pacific Islander American Indian/Alaskan Native Other

How did you hear about "Walk 4 Wellness":

FYI Flier Wellness Zone Wt. Loss 101 Diabetes WS Web Link Other

How frequently do you engage in physical activity?

Days/Week:

Time/Day: Less than 20 min 20-40 min more than 40 min

How would you define regular physical activity?

going to the gym 3 times a week playing sports accumulating 30 minutes or more most days of the week vigorous exercise for a continuous 20 min most days moderate exercise for at least 30 continuous min most days

Please check the statement that best applies to you currently:

I am presently active on a REGULAR basis and have been doing so for longer than 6 months

I presently am active on a REGULAR basis, but have only begun doing so within the last 6 months.

I intend to become active on a REGULAR basis within the next month.

REGULAR activity is defined as moderate intensity (walking, gardening, stairs, housework, jogging, etc), accumulated 30 minutes or more 4+ days per week.

I attest that the information contained herein is true and complete to the best of my knowledge. I understand that the Walk 4 Wellness program is a community effort intended to promote and increase the health of its participants. In return for the privilege of participating in the program, I agree for myself and for my heirs, executors, administrators, and assigns to waive and release any and all claims I may have against the Walk 4 Wellness program sponsors, the organization of which I am participating, and all their directors, trustees, officers, employees and representatives arising from injuries or illnesses by me relating to my participation in this program. If I have uncontrolled asthma, uncontrolled high blood pressure, a history of heart problems, or if I have other serious or chronic health problems, or if I am over 40 years of age, I understand that I am responsible for consulting my doctor or health practitioner before beginning this program.

I agree to the above statement:
Yes No

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