Go Walk Houston Campaign Registration Form

Thank you for your participation in the Go Walk Houston campaign! Please complete the following Registration Form to help us measure the impact of the campaign and to highlight and promote your success!
Contact us at Gowalkhouston@houstontx.gov

Share your activities on social media using #GoWalkHouston

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* 1. Today's Date

Date:

Date

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* 2. Organization Information:

Name:

Address:

Phone:

Web Address:

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* 3. Point of Contact Information:

Name:

Email Address:

Phone Number:

Job Title:

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* 4. Sector of Organization:

Employer/Business

Education/ Academic Institution

Non-Profit

Healthcare /Medical

Media

Government

Transportation, Land Use & Community Design

Other (please specify)

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* 5. Size of Organization:

0-49 Employees

50-499 Employees

500-999 Employees

1000- 4999 Employees

5000+ Employees

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* 6. Does your organization currently have a workplace wellness policy or program?

Yes

Please Describe:

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* 7. GO WALK HOUSTON ACTIVITY DESCRIPTION
Please describe your fitness related project, program, policy, or activities in support of the Go Walk Houston Campaign.

Activities start Date:

Activities end Date:

Type of Event:

Event Description:

Location of event:

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* 8. Is there a walking path, park, or trail on or near your worksite?

Yes

Please Describe:

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* 9. Does your company’s physical location have bike racks?

Yes

Please Describe:

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* 10. Average Age of Employees:

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* 11. **Gender of Workforce (Estimation):**

% Male:

% Female:

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* 12. **Race/ Ethnicity of Employees (Estimation):**

% Non- Hispanic White:

% Non- Hispanic Black/African American:

% Hispanic/ Latino:

% Asian:

Other:

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* 1. Today's Date

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* 2. Organization Information:

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* 3. Point of Contact Information:

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* 4. Sector of Organization:

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* 5. Size of Organization:

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* 6. Does your organization currently have a workplace wellness policy or program?

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* 7. GO WALK HOUSTON ACTIVITY DESCRIPTIONPlease describe your fitness related project, program, policy, or activities in support of the Go Walk Houston Campaign.

Question Title

* 8. Is there a walking path, park, or trail on or near your worksite?

Question Title

* 9. Does your company’s physical location have bike racks?

Question Title

* 10. Average Age of Employees:

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* 11. Gender of Workforce (Estimation):

Question Title

* 12. Race/ Ethnicity of Employees (Estimation):

* 7. GO WALK HOUSTON ACTIVITY DESCRIPTION
Please describe your fitness related project, program, policy, or activities in support of the Go Walk Houston Campaign.

* 11. **Gender of Workforce (Estimation):**

* 12. **Race/ Ethnicity of Employees (Estimation):**