2017 Challenge Administration 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.
Company/Organization
Your answer
Group ID (if known)
Your answer
Eligible Population
Your answer
Contact Person:
Your answer
Title:
Your answer
Email Address:
Your answer
Phone:
Your answer
Address:
Your answer
City:
Your answer
State:
Your answer
Postal Code:
Your answer
County:
Your answer
Payment Method
*If the company/organization elects to pay for all or a portion of the registration fee, an invoice will be sent to the contact above after registration closes on February 6, 2017.
Required
If you selected 'Company/Organization will pay a portion of the $20 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:
Your answer
Marketing Materials
Electronic copies of the following promotional materials will be available in the toolkit on the Administrator dashboard, accessible after account setup. If you would like hard copies of any of these materials, please indicate the quantity below.
Brochure:
Your answer
Flier (8.5" x 11"):
Your answer
Poster (11" x 17"):
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Statement of Confidentiality:
By entering my name and the date of submission below, 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.
Your answer
I am also interested in these other upcoming LHI challenges and events:
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