ARC Participation Form

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Thank you for your interest in ARC's free 4 week program to be held on Wednesday nights from 530-630pm for 4 weeks, April 27- May 18, location TBD. Movement is an incredible tool to boost your physical and mental health.

Your responses are very important to us. Please respond thoughtfully with as much detail as possible.

We are so excited for you to begin this amazing journey!!

***Parents, if your daughter needs assistance completing the application, please feel free to help her respond to the questions.

First Name *

Last Name *

Parent First Name *

Parent Last Name *

Parent question: do you feel that your daughter will get more out of the program if you participate with her? *

Yes

Parent question: would you be willing to participate with your daughter? *

Yes

Is your daughter currently able to walk 2-5 minutes?

Yes

Clear selection

Phone Number *

Tell us a bit about you and your journey including details on specific special needs. *

If selected to participate, what are your goals for the ARC program? *

Tell us about your dreams and aspirations. *

Tell us about any barriers to running that you have experienced (examples include: access, health issues, race, ethnicity, body type, perceived ability, etc.). *

Do you currently have any health concerns or pain symptoms? *

If you have had pain over the last month, please include additional information (Where is the pain located? Are you currently taking medication for pain? Are you seeing a doctor? Do you have any restrictions?). This information is very important for our team! *

In your opinion, do you have good/supportive shoes for exercising? Why or why not (please include any information on financial barriers).

Which of the following benefits of running are most important to you? (select three that are most applicable) *

Improved cardiovascular health

Improved blood pressure

Delayed aging

Improved sleep

Improved stress management

Weight management

Increased bone density

Prevention of diabetes/improved glucose regulation

Improved Resiliency

Improved Sleep

Improved Stress Management

Reduced Cholesterol

Boosted Immune System

Reduced Risk of Cancer

Increased Bone Density

Increased Energy

Required

Parent question: what is your annual income? *

Please enter your age: *

Please enter your gender *

Female

Male

Do you have access to Health Care? *

Yes

Required

Parents: what is the highest level of education that you have completed? *

High School Diploma/GED

Technical Schooling or Professional Certificate

Bachelor's Degree

Master's Degree or Doctorate

Required

Ethnicity/Race (check all that apply) *

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Required

Street address

City

State

Zip code

How do you prefer we communicate with you? *

Can ARC use your demographics and data (name will be omitted) as we compile the research needed to raise funds to continue to empower future participants through the ARC program?

Yes

Clear selection

Can ARC post or repost your pictures/videos to build awarenes as week seek to empower future participants through the ARC program?

Yes

Clear selection

You may also submit a video (no longer than 1 minute) to ARC telling us more about your story and why you'd like to be a part of the progam. Please email your video to TeamARC@activeresoluteconnected.com (video is optional). Please indicate below if you intend to submit a video.

Yes

Clear selection

Submit

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