WWC Fall 2015 Survey

Thank you for applying for the Healthworks Workplace Warrior Challenge! Each team must be comprised of up to eight female employees (minimum of six) from the same organization. You may have a maximum of two Healthworks members on your team. In order to complete the application you will need to know the full name, email address, phone number, and birthdate month and birthdate year of each team member, as well as your group's preferred time and location. Applications with incomplete information will not be considered for the challenge.Good luck!

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* 1. Employer:

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* 2. Team Name (please incorporate the name of your employer into your team name):

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* 3. Preferred Day & Time for Group Personal Training:

Back Bay; Thursdays 5:30pm

Back Bay; Fridays 6:00am

Back Bay; Tuesdays 12:00pm

Cambridge; Mondays 7:00am

Cambridge; Fridays 5:00pm

Cambridge; Sundays 12:00pm

Chestnut Hill; Mondays 7:00am

Chestnut Hill; Thursdays 6:00pm

Chestnut Hill; Wednesdays 6:30pm

Coolidge Corner; Mondays 6:00pm

Coolidge Corner; Tuesdays 7:00pm

Coolidge Corner; Fridays 6:00am

If you have selected more than one day & time, please rank them in order of preference:

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* 4. Why should your team be chosen for the Workplace Warrior Challenge?

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* 5. Team Captain Contact Information:

Name:

E-Mail Address:

Phone Number:

Is the Team Captain a Healthworks member (Y or N)?

Preferred Healthworks location for individual visits:

Birthday Month

Birthday Year

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* 6. Additional Team Member Contact Information:

Name:

E-Mail Address:

Phone Number:

Is the team member a Healthworks member (Y or N)?

Preferred Healthworks location for individual visits:

Birthday Month

Birthday Year

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* 7. Additional Team Member Contact Information:

Name:

E-Mail Address:

Phone Number:

Is the team member a Healthworks member (Y or N)?

Preferred Healthworks location for individual visits:

Birthday Month

Birthday Year

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* 8. Additional Team Member Contact Information:

Name:

E-Mail Address:

Phone Number:

Is the team member a Healthworks member (Y or N)?

Preferred Healthworks location for individual visits:

Birthday Month

Birthday Year

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* 9. Additional Team Member Contact Information:

Name:

E-Mail Address:

Phone Number:

Is the team member a Healthworks member (Y or N)?

Preferred Healthworks location for individual visits:

Birthday Month

Birthday Year

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* 10. Additional Team Member Contact Information:

Name:

E-Mail Address:

Phone Number:

Is the team member a Healthworks member (Y or N)?

Preferred Healthworks location for individual visits:

Birthday Month

Birthday Year

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* 11. Additional Team Member Contact Information:

Name:

E-Mail Address:

Phone Number:

Is the team member a Healthworks member (Y or N)?

Preferred Healthworks location for individual visits:

Birthday Month

Birthday Year

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* 12. Additional Team Member Contact Information:

Name:

E-Mail Address:

Phone Number:

Is the team member a Healthworks member (Y or N)?

Preferred Healthworks location for individual visits:

Birthday Month

Birthday Year

Congratulations! You have completed your application for Workplace Warrior Challenge!