Gold Shoe Step It Up Challenge 2017 Gold Shoe Step It Up Challenge Registration and Newsletter Sign UP Question Title * 1. If you've already registered click here to record your steps and activity.The Gold Shoe Step It Up Challenge is a free community walking program designed to get Chemung County moving!! Thanks to those that joined us for the initial screenings.You can earn raffle ticket for prizes now by finding a Gold Shoe.Prizes will be raffled off at our final event on Saturday, June 10th, at 10 am at Tanglewood Nature Center.Please provide the following information to register:All information is kept strictly confidential.Thanks to those that joined us for the initial screenings.Final screenings will be:Monday, June 5th from 10 am to 2 pm at the Chemung County Health Dept. orThursday, June 8th from 5 to 7 pm at Arnot MallThis is for those that participated in the initial screenings. Name ZIP/Postal Code Email Address Phone Number Question Title * 2. When were you born? Please enter as MM/DD/YYYY ie. 05/26/1971 Date / Time Date Question Title * 3. Which race/ethnicity best describes you? (Please choose only one.) American Indian or Alaskan Native Asian / Pacific Islander Black or African American Hispanic White / Caucasian Multiple ethnicity / Other (please specify) Question Title * 4. What is your gender? Female Male Other (specify) Question Title * 5. Which initial screening will you attend? You must attend initial and final screenings OR find a Gold Shoe to be eligible for prizes. Initial screenings are 4/24 or 4/27. Final screenings will be in June. Monday, 4/24 from 10 am to 2 pm at the Chemung County Health Dept. Thursday, 4/27 from 5 pm to 7 pm at the Arnot Mall in the Community Connection Room near Penney's Unsure I will not be attending a screening Question Title * 6. Please answer yes or no: Yes No Have you attended Gold Shoe or Step It Up activities in the past? Have you attended Gold Shoe or Step It Up activities in the past? Yes Have you attended Gold Shoe or Step It Up activities in the past? No Have you been diagnosed with diabetes? Have you been diagnosed with diabetes? Yes Have you been diagnosed with diabetes? No Question Title * 7. Please tell us your height and weight so we can track your progress - all information remains strictly confidential. Please enter your height in inches. For example, 5 feet 4 inches as 64 and your weight in pounds. Height in inches Weight in pounds Question Title * 8. How did you hear about the Gold Shoe Step It Up Challenge? Check all that apply. Facebook Television Poster or flyer Friend, co-worker, or family member Newspaper Email Other (please specify) Next
