Walk for Wellness Registration

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Email *

What is your first and last name? *

What is your sex

Female

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Male

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Demographic Data (Mark Which Applies)

White

Black/African American

Asian

American Indian/Alaskan Native

Native Hawaiian/Pacific Islander

Other

Hispanic/Latino

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How did you hear about the Walk for Wellness? *

Emergency Contact (Name & Phone Number): *

What is your activity level? *

Beginner

Intermediate

Advanced

Do you have any concerns about joining the Walk for Wellness Group? *

The coordinator for the Walk for Wellness Group is Marlana Baker, Family and Consumer Science Agent at the N.C. Cooperative Extension.

To contact Marlana Baker for further questions please call (828)837-2210 or send an email to marlana_baker@ncsu.edu.

A copy of your responses will be emailed to the address you provided.

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