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* 1. 1.      Please list the things you currently do in your daily life to stay physically active.

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* 2. ) Do you typically do these things alone or with others?

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* 3. Select the activities you would participate in if made available by a Saint Ambrose Active Adult Ministry Program. Please write in any activities, not listed here, that you would participate in if made available.

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* 4. 4. Would you or someone you know be willing to organize a group that participated in one of these activities?

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* 5. If yes, write down your name and contact information or the name and contact information of the person you recommend below.

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