Physical Activity Inventory Survey

Physical Activity Inventory

1. Physical Activity Opportunity Inventory

The Kanawha-Charleston Health Department in partnership with the Kanawha Coalition for Community Health Improvement and CAMC Institute have been awarded a Robert Wood Johnson Foundation Healthy Kids Healthy Communities grant. The grant entitled "Keys 4 HealthyKids" will focus on policy and environment changes in regards to physical activity and nutrition. The Physical Activity Guide will be published on-line and a print format version will be available for download at our website.

Please complete the following information about your facility: Facility Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Website:
Email Address:
Phone Number:

Hours of Operation Mon
Tue
Wed
Thu
Fri
Sat
Sun

Is there a fee associated with use of the facility? Free Pay at the Door	Pay for Only Certain Programs Membership Required	Other
If yes, how much?

Type of Facility Bowling Alley Campground Church Facility City/Community Facility Community Center Dance Studio Exercise Facility	Golf Course Mall Martial Arts Park: City, County, State or National Recreation Facility School Facility Senior Program or Center	Skaing Arena or Rink Special Needs Porgram Sports Club Swimming Pool Trail/Walking Path Yough Program
Other (please specify)

Physical Activity Inventory
Exit this survey

1. Physical Activity Opportunity Inventory

1. Please complete the following information about your facility:

2. Days of Operation

3. Hours of Operation

4. Is your facility open to the general public?

5. Is your facility ADA accessible?

6. What age group does your facility serve?

7. Is there a fee associated with use of the facility?

8. Type of Facility

9. Type of Activities, Features or Amenities:

10. Please describe your facility in one hundred words or less.

*
11. Submitted By

Physical Activity InventoryExit this survey

1. Physical Activity Opportunity Inventory

1. Please complete the following information about your facility:

2. Days of Operation

3. Hours of Operation

4. Is your facility open to the general public?

5. Is your facility ADA accessible?

6. What age group does your facility serve?

7. Is there a fee associated with use of the facility?

8. Type of Facility

9. Type of Activities, Features or Amenities:

10. Please describe your facility in one hundred words or less.

*11. Submitted By

Physical Activity Inventory
Exit this survey

*
11. Submitted By