Gold Shoe Step It Up Challenge 2017

Gold Shoe Step It Up Challenge Registration

If you've already registered click here to record your steps/activity

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* 1. The Gold Shoe Step It Up Challenge is a free community walking program designed to get Chemung County moving!!

Join us for FREE screenings:
Monday, April 24th from 10 am to 2 pm at the Chemung County Health Dept.
Wednesday, April 26th from 5 to 7 pm at the YWCA in Elmira or
Friday, April 28th from 5 to 7 pm at Arnot Mall
An extra raffle ticket for prizes will be given to all who do before and after screenings.
Prizes will be raffled off at our final event on Saturday, June 10th, at 10 am at Tanglewood Nature Preserve.

Please provide the following information to register:

All information is kept strictly confidential.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. When were you born? Please enter as MM/DD/YYYY ie. 05/26/1971

Date / Time

Date

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* 3. Race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Some other race (please specify)

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* 4. Gender?

Male

Female

Other (please specify)

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* 5. Have you used any of the following tobacco products in the last 12 months?

	Yes	No
Cigarettes	Cigarettes Yes	Cigarettes No
Cigars	Cigars Yes	Cigars No
Chewing tobacco	Chewing tobacco Yes	Chewing tobacco No
E-cigarette (vaping)	E-cigarette (vaping) Yes	E-cigarette (vaping) No
Pipe	Pipe Yes	Pipe No

Other (please specify)

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* 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

Other (please specify)

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* 7. Please tell us your height and weight so we can track your progress - all information remains strictly confidential. For example enter 5 feet 4 inches or 5'4" or 64 inches and your weight in pounds

height

weight

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* 8. How did you hear about the Gold Shoe Step It Up Challenge?

Facebook

Newspaper

Friend, co-worker, family

Poster/flyer

Other (please specify) ie. flyer at Eldridge Park

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* 9. Thank you! Do you have a few more minutes to answer some health related questions? This will make your sign in at our kick off event go faster.

Yes