Step It Up for Adoption

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Complete this form to be entered into the step competition!

Email Address *

Name *

Are you participating with a certain company? If yes, please enter name of company below.

Location (City and State)

How would you like to pay? *

Paypal

Cash

Check

What kind of Pedometer will you be using?

Just a regular pedometer

My phone

Fitbit (or something like it)

Clear selection

Do you have a goal in mind?

(Please choose as second goal if you choose TO WIN as your goal)

No. I want to surprise myself.

Yes, TO WIN

Yes, I have a daily goal of 5000 steps a day (that's 75 miles in 30 days!)

Yes I have a monthly goal of 100 miles (that's 7040 steps a day)

Yes, I have a daily goal of 10,000 steps (that's 142 miles!)

Yes, I have a monthly goal of 200 miles (that's 14,080 steps a day)

Clear selection

What would be a super awesome prize?

Keep in mind, the more people who join, the bigger the prize! So share this with all your friends

Fitbit One (at least 25 participants)

Amazon Gift Card

Beats Solo HD Headphones (at least 35 participants)

Kindle Paperwhite (at least 25 participants)

Itunes Gift Card

Cinemark Gift Card

GoPro Hero 3 (at least 45 participants)

Roku 3 (at least 25 participants)

Cash!

Other:

Clear selection

Submit

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