REACH OUT PARTICIPANTS

ReachOut is a project to help children and families live healthier lifestyles. Our activities include walking groups, healthy eating/cooking classes, nutrition consultation, family sports, health education, and referrals to medical and social services. Please complete the survey in order to participate in our activities.

 
What is your name? *
 

What is your mailing address, email and phone number? *
 

What is your date of birth? *
 

Do family members under 19 have health insurance? *
  Yes
  No

If no, can we assist you in applying for Healthy Families? *
Healthy Families is a low cost insurance for children and teens.
 

Which of the activities are you and/or family members interested in?
  AM Neighborhood Walking Groups
  PM Neighborhood Walking Groups
  Saturday AM Trails
  Water Sports- Rowing, swimming
  Dance- Aerobics, Jazzercise, Salsa
  Yoga, Meditation, Tai Chi,etc.
  Family Sport Teams-volleyball, soccer, basketball, softball
  Mothers/Preteen Wellness University
  Sons/Fathers Overnight Camping
  Healthy Eating/ Cooking Classes
  Nutrition Consultation
  Weight Loss Groups
  Marathons and Tournaments
  Mind, Body, Spirit Healing Workshops
  Community Gardening

Do you have family members at risk or diagnosed with Obesity, Type II Diabetes, High Blood Pressure or other Chronic Disease? *
  Yes
  No
  Not Yet

Will you be interested in volunteering, leading walking groups, or sharing your health story?
  Yes
  No
  Maybe, I need more information