Activate Butler County Registration Form
Please click on the Submit button to submit the form details.
*
indicates required fields
Name:
*
Email Address:
Street Address:
City:
State:
Zip Code:
Age:
Gender:
Female
Male
Select the one that best describes you:
I will not exercise
I think about exercising
I exercise less than 4 days/week
I exercise more than 4 days/week
How many days per week are you active?:
0
1
2
3
4
5
6
7
Your activity goal in minutes per week:
How motivated are you (1-10)?:
Reasons you want to be active:
Improve my physical health
Feel better about myself
Improve my appearance
Win a prize
Motivation for regular exercise
Motivation to increase activity
Family or friends encouraged me
Promotional message motivated me
Reverse diagnosis of disease
Do you eat 5 fruits/vegetables per day?:
Yes
No
Log in your activity minutes every week:
OK!
Please click on the Submit button to submit the form details.
Community Wellness Committee of the Butler Collaborative for Families
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