Walking Group Registration

  
First Name*
Last Name*
Address*
City*
State*
Zip Code*
Email
Home Phone
Cell Phone
Church Affiliation
Preferred Walking Time (Please Indicate AM or PM)*
Do You Walk Regularly?*
 Yes
 No
If yes, please explain the distance (How far you walk) and location (Where you walk).
Do You Have a Walking Partner?*
 Yes
 No
Would You Like a Walking Partner?*
 Yes
 No
Do You Have Any Health Related Matters That May Be Impacted By Exercise?*


Submit