2019 Burst Your Thirst Challenge Administration Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

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 *

Employee Population *

Contact Person: *

Title: *

Email Address: *

Phone: *

Address: *

City: *

State: *

Postal Code: *

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.

Team captains will be responsible for the $10 registration fee for each team member at the time of registration

Company/Organization will pay the $10 registration fee for each participant*

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*

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:

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.

I am also interested in learning more about:

Live Healthy Iowa 5K Run/Walk

Strut Your Pup Challenge | Apr-May

Burst Your Thirst Challenge | Jun-Jul

The Next Step Challenge | Sep-Oct

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms