2019 Burst Your Thirst 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
Employee 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: *
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 June 17, 2019.
Required
If you selected 'Company/Organization will pay a portion of the $10 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
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 Burst Your Thirst Challenge.
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