Please complete the following ... Let's get healthy together!!

* 1. Please provide the following information

* 2. What is your date of birth and how old are you?

* 3. Which components of the program are you interested in?

* 4. If you are signing up for the Weight Loss Challenge, which weigh-in site are you planning to use?

* 5. How did you hear about Waldwick's Wellness Challenge?

* 6. By registering for the Weight-Loss Challenge, you agree to the following... You are at least 18 years of age and older, and Before beginning any weight loss or exercise regimen, an individual should consult with their personal physician to ensure that they are healthy enough to participate. By signing below, the individual agrees to take personal responsibility for any actions which are part of the Wellness Challenge. The individual agrees to hold harmless and waive any responsiblity of the Borough of Waldwick, any individual or partner of the Borough of Waldwick in performing the Wellness Challenge, or of any other municipality and their partners that are participating in performing the Wellness Challenge and any activity that may be offered throughout Bergen County as part of the Wellness Challenge.

* 7. By registering for Waldwick's Wellness Challenge, you agree to the following:  I grant NorthWest Bergen Regional Health Commission and the Borough of Waldwick the right to take photographs of me and/or my family in connection with Waldwick's Wellness Challenge.  I authorize its assigns and transferees to copyright, use and publish the same in print and/or electronically.  I agree that they may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and Web content.