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Name:
*First:
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MI:
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*Last:
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Gender: |
Male
Female |
Age: |
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Department Name: |
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Department Physical Location: |
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*Messenger Mail Address : |
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*Work Phone: |
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*Email Address: |
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Employee Classification: |
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What is your current physical activity level?
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| What time of day do you currently or would you be interested in walking? |
Before work
Lunch time
After work
Other
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| Why are you interested in a walking program? |
Please check all that apply:
Weight loss,
Increase energy level,
Stress relief,
Build teamwork
Other
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| Would you be interested in being a walking team coordinator for your department or building? |
Yes
No |
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What is your weekly walking goal during the six week walking program?
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During each walking session, I plan on walking:
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Are you interested in an onsite Weight Watchers program? |
Yes
No
If so, When would be the best time for you to attend the meetings?
Before Work
During Lunch
After Work
Where would you like the meetings to be held? Please specify building: eg. "Stacy Hall":
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Any Questions or Comments?
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