2020 10 Week Wellness Challenge - Group ID/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.
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 January 27, 2020.
Required
If you selected 'Company/Organization will pay a portion of the $22 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 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.
Your answer
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