Healthy Androscoggin - Get Fit and Win Registration

Get fit and win registration

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Thank you for your interest in the program. Please complete the following information to participate in Get Fit & Win. Please be honest because this information will be used to help track and evaluate our efforts.

Due By: June 7th, 2008
Healthy Androscoggin
300 Main Street
Lewiston, ME 04240
Fax: 795-5992
info@healthyandrosocoggin.org

Name:
Age:
Gender:
Address:
City:
Zip:
Phone:
Email:
What is your preferred method of communication?
Have you participated in Get Fit & Win in the past?
How many days per week do you currently exercise? days per week
If you identify an exercise buddy and you record on your log that you exercised with him or her at least 3 times during Get Fit and Win, you will be entered into an additional drawing for $250.
Buddy’s Name: (buddy does not need to be signed up for Get Fit & Win, but if the buddy signs up then they could be eligible for prizes too!)

Activity goal and Kick Off Walk/Run

Please select the physical activity goal that seems best for you based on your current activity level and the activity challenge you have set for yourself:

30 minutes per day for 3 days a week
30 minutes per day for 5 days a week
45+ minutes per day for 5 days a week

How did you hear about the Get Fit & Win program?

If you heard about the program through a community poster, school or work, what is the name of your school, worksite or poster location?

Events and Reminders

On Monday, June 9th meet us at the Bates College track on Russell St at 5pm to start getting active. Come get your free pedometer (first 50 participants that day) and then walk, or run at your own pace. (This is optional.)

Would you like to pick up your Get Fit & Win materials on June 9th or receive them in the mail?

	I'll pick them up on June 9th
	Please send them in the mail.

Get Fit & Win Materials include:

Free copy of: Recreational Opportunities in Androscoggin County: A Resource Guide.
Activity Log Sheet - complete to enter to win. Email, mail or fax completed logs to Healthy Androscoggin by July 31st
List of Community Events that give you more opportunities have fun and be active.
Watch for periodic email tips from Healthy Androscoggin.