Southern WV on the Move! Program Survey 2010 - 2011

1. General Information

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Thank you for completing this program evaluation survey for Southern WV on the Move! Six Week Walking Program. Your responses are confidential and are only used to determine the effectiveness of this program. Thanks to our funders: Logan Healthcare Foundation.

1. Please provide some general information:

Please provide some general information: First Name:
Last Name:
Address:
City:
County:
State:
ZIP/Postal Code:
Email Address:

2. Please provide your birth date:

	MM		DD		YYYY
MM/DD/YYYY	Please provide your birth date: MM/DD/YYYY Month	/	Day	/	Year

3. Where did you register for this program? Check all that apply:

Where did you register for this program? Check all that apply: Activate for Healthy Tomorrow, Boone County

All About Health Relay for Life, Boone County

Boone Memorial Health Fair, Boone County

Boone County Health Department, Boone County

CEOS Walking Club, Wyoming County

Chapmanville on the Move!, Logan County

Chief Logan Recreational Center, Logan County

Chief Logan State Park, 5k Run/Walk, Logan County

Delbarton Seniors on the Move!, Mingo County

Fifth Avenue Church of Christ, Mingo County

Healthy Children/Healthy Families, Wyoming County

Lincoln County Opportunity, Inc., Lincoln County

Larry Joe Harless Community Center, Mingo County

Man on the Move!, Logan County

Matewan Senior Center, Mingo County

Southern WV Technical & Community College, Wyoming County

Twin Falls State Resort, Wyoming County

West Logan on the Move!, Logan County

Workforce Logan, Logan County

Diabetes Coalition, Walk at Lunch, Mingo County

Other (please specify)

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