Eat Smart, Move More Registration

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Please complete the information requested below. After submitting the form, you will receive an email with online registration instructions for the program. Please watch for an email from alisa.lammers@co.barron.wi.us within 24 hours of submitting the form below. This form requires an e-mail. If you prefer to answer these questions over the phone, please call Alisa at 715-537-6225.

The Eat Smart, Move More is an online 15 week nutrition & physical activity program designed to build healthy habits! The Aging & Disability Resource Centers of Barron & Rusk County will be covering the cost (a $235 value) for participants age 60 and older for a limited time. Donations are accepted for $10 per participant.

Email *

Name (first & Last) *

Street Address *

City *

Zip *

County You Reside In: *

Barron

Rusk

Telephone (including area code) *

The following information you are being asked to provide is needed to determine if you are eligible to receive Older Americans Act Services and to comply with federal reporting requirements. This information will be stored in a secure electronic database and will not be used for any other purpose. Your information will not be shared with another agency without your permission. This information will not be sold to anyone. You have the right to review your electronic record and request changes to assure accuracy. You will not be denied most services if you refuse to provide this information. If you have questions regarding this, please contact the Aging and Disability Resource Center of Barron and Rusk counties at 1-888-538-3031.

Date of Birth *

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Gender

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Female

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Gender Identity

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Female

Transgender Male

Transgender Female

Transgender Unspecified

Gender Non-conforming

Gender Fluid/Non-Binary

Other:

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Race

Hispanic

Asian or Asian-American

Hawaiian Native or Pacific Islander

American Indian/Alaska Native

Black or African American

White or Causasian

Multi-Racial

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Ethnicity

Hispanic or Latino

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Marital Status

Married

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Partnered

Never Married

Other:

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How Many People Live In Your Household?

Income Level:

My income is below this amount

My income is at or over this amount

Single Person $1133 monthly income

2 Person Household $1526 monthly

3 in household $1919 monthly

4 or more in household $2313 monthly

A copy of your responses will be emailed to the address you provided.

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