2022 10 Week Wellness Challenge - Group ID and Subsidy Request Form
Thank you for your interest in organizing a Live Healthy Iowa (LHI) Challenge within your business, community or organization! Please complete and submit this form at your earliest convenience. Once the form is received, LHI will establish, or update your account, and send further details via email.
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Company/Organization *
Employee Population *
Contact Person: *
Title: *
Email Address: *
Phone: *
Address: *
City: *
State: *
Postal Code: *
County: *
T-Shirt Shipping *
This year there are two options for shipment of t-shirts. You can choose to have t-shirts for your organization go to one company admin or have them go to each respective team captain. Please let us know which option your organization prefers.
Required
T-Shirts
If you selected to ship T-shirts to the company admin, please provide the name and address for shipping. If you did not choose this option, please put N/A.
Payment Method *
*If the company/organization elects to pay for all or a portion of the registration fee, an invoice will be sent by email to the contact above after registration closes on January 24, 2022.
Required
If you selected 'Company/Organization will pay a portion of the $25 registration fee for each participant with team captains paying the remaining amount at the time of registration', please input the amount to be paid by the company/organization below:
Marketing Materials
Electronic copies of a promotional flier and poster will be available in the toolkit on the Administrator dashboard, accessible after account setup. Please indicate below if you'd like a customized version, including the Group ID and/or Subsidy Code, for your company or organization. The customized flier and/or poster will be sent to you via email with account details.
Customized Flier:
Customized Poster:
Statement of Confidentiality: *
By entering my name, I agree to keep participant information confidential and not use privileged information in any way other than the encouragement and promotion of the Live Healthy Iowa 10 Week Wellness Challenge.
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