Exit this survey

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Please indicate your UCLA affiliation:

Question Title

* 4. Please enter your 9-digit staff ID # (found on your BruinCard):

Question Title

* 5. Department

Question Title

* 6. Gender

Question Title

* 7. Email (used for event updates and to contact prize winners by Friday May 20)

Question Title

* 8. Which walking location do you plan to attend on 5/17 from 12-1p?

Walks will start at 12:10p & 12:15p for Main Campus & RR Medical Center. Please plan to arrive at 12p to leave time for check-in and tshirt pick up.

**SM Hospital & FPG/LAX locations have different walking times**

Question Title

* 9. Is this your first time attending this event?

Question Title

* 10. How did you hear about this event?

Question Title

* 11. If you were to win a raffle prize, please indicate which prize you'd prefer:

Question Title

* 12. Are you currently a member of UCLA Recreation? If not check out our great packages at www.recreation.ucla.edu/join

Questions 13-16 are optional, however these questions are geared toward collecting data that will help to develop and improve FITWELL Programs for Faculty and Staff. Responses are confidential and will not be shared.

Question Title

* 13. On average, how would you rate your ability to cope with daily stress?

Question Title

* 14. Number of times you have engaged in any type of physical activity for more than 30 minutes for the past week? (walking, gardening, cleaning, etc.)

Question Title

* 15. In which of the following categories would you place yourself?

Question Title

* 16. Which of the following FITWELL programs have you participated in? Check all that apply.

Question Title

* 17. Please type full name below once waiver here has been read. I understand my signature is being transferred electronically, and I will not challenge the validity of the signature in any legal proceeding in which this document may be offered or used.

( Privacy & Cookie Notice

T