REGISTRATION FORM

• • INFO
• • FAQ
• • REGISTRATION
• • CHALLENGE EVENTS

Please select the response that best applies to you:
Items marked with an asterisk (*) are required

How would you describe your current overall health and well-being?

-- Select -- Fair Average Good Excellent

 

How would you describe your current level of physical activity?

-- Select -- Fair Average Good Excellent

 

Are you currently eating 5 fruits and vegetables a day?

-- Select -- Yes No

How ready are you to make some healthy lifestyle changes?

-- Select -- Yes I am ready I have been thinking about it No, but I am willing to try This program will get me started  

Where did you hear about the Mayor's New Year New You Challenge?

-- Select -- Radio Television E-mail Get Moving Houston Website City Location Other  

 

Name*

Address*

City*

State*

Zip*	Home Phone

E-mail Address*

 

Mayor’s New Year New You Challenge Program Waiver

I am voluntarily participating in the Mayor’s New Year New You Challenge program.  I understand that there are inherent risks to exercising, and if I have not been physically active I should consult my physician before beginning such a program.  I hold the Mayor’s New Year New You Challenge and its subsidiaries blameless for any injuries, health concerns or other problems that may occur.