**2016 Go for the Gold Well-Being Challenge**

Registration

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* 1. Please list contact information:

First Name

Last Name

Work Department

Work Location

Email Address

Email Address for verification

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* 2. How do you rate the following health components in your life?

	Poor	Average	Excellent
Drinking water, staying hydrated 64 oz per day	Drinking water, staying hydrated 64 oz per day Poor	Drinking water, staying hydrated 64 oz per day Average	Drinking water, staying hydrated 64 oz per day Excellent
Nutrition, eating 5 servings of fruits and vegetables daily	Nutrition, eating 5 servings of fruits and vegetables daily Poor	Nutrition, eating 5 servings of fruits and vegetables daily Average	Nutrition, eating 5 servings of fruits and vegetables daily Excellent
Stretching, incorporating 10 minutes of flexibility when exercising	Stretching, incorporating 10 minutes of flexibility when exercising Poor	Stretching, incorporating 10 minutes of flexibility when exercising Average	Stretching, incorporating 10 minutes of flexibility when exercising Excellent
Strength training, incorporating resistance training exercises 3 times per week	Strength training, incorporating resistance training exercises 3 times per week Poor	Strength training, incorporating resistance training exercises 3 times per week Average	Strength training, incorporating resistance training exercises 3 times per week Excellent
Overall fitness level	Overall fitness level Poor	Overall fitness level Average	Overall fitness level Excellent

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* 3. In a typical week, how many days do you exercise?

I don't regularly exercise

Once a week

2 to 4 days a week

5 to 7 days a week

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* 4. How many minutes of exercise do you complete each week?

0 minutes, I do not exercise

60 minutes or less per week

90 minutes or more per week

150 minutes or more per week

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* 5. At what intensity do you most often exercise?

Low intensity

Moderate intensity

High intensity, breathless

I do not exercise

Other (please specify)

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* 6. How do you rate support/encouragement for physical activity at work?

Low, not supported.

Medium, I feel I have opportunity or encouragement to be active and my co-workers and I encourage each other.

High, I always have support at work, we talk about well-being and our goals often.

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* 7. What do you hope to achieve or gain by participating in the Go for the Gold well-being challenge?

Improve fitness level

Spend more minutes each week being physically active

Education, learning the recommendations for an overall active and fit lifestyle

Fun, amplify unity and stronger connection with co-workers and organization

Other

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* 1. Please list contact information:

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* 2. How do you rate the following health components in your life?

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* 3. In a typical week, how many days do you exercise?

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* 4. How many minutes of exercise do you complete each week?

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* 5. At what intensity do you most often exercise?

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* 6. How do you rate support/encouragement for physical activity at work?

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* 7. What do you hope to achieve or gain by participating in the Go for the Gold well-being challenge?

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* 8. Please share other well-being goals.