IHWI Annual Task Force Meeting 2014 Question Title * 1. Contact Information: Name Phone Number Email Position Title Organization Street Address City, State, Zip Code Question Title * 2. Please rank your interest in the Work Groups from 1 to 9. The greatest interest being 9 and lowest interest being 1. 1 2 3 4 5 6 7 8 9 Worksite Worksite 1 Worksite 2 Worksite 3 Worksite 4 Worksite 5 Worksite 6 Worksite 7 Worksite 8 Worksite 9 Schools Schools 1 Schools 2 Schools 3 Schools 4 Schools 5 Schools 6 Schools 7 Schools 8 Schools 9 Child Care Child Care 1 Child Care 2 Child Care 3 Child Care 4 Child Care 5 Child Care 6 Child Care 7 Child Care 8 Child Care 9 Breastfeeding Breastfeeding 1 Breastfeeding 2 Breastfeeding 3 Breastfeeding 4 Breastfeeding 5 Breastfeeding 6 Breastfeeding 7 Breastfeeding 8 Breastfeeding 9 Older Adults Older Adults 1 Older Adults 2 Older Adults 3 Older Adults 4 Older Adults 5 Older Adults 6 Older Adults 7 Older Adults 8 Older Adults 9 Health Care Health Care 1 Health Care 2 Health Care 3 Health Care 4 Health Care 5 Health Care 6 Health Care 7 Health Care 8 Health Care 9 Faith Based Faith Based 1 Faith Based 2 Faith Based 3 Faith Based 4 Faith Based 5 Faith Based 6 Faith Based 7 Faith Based 8 Faith Based 9 Communities: Built Environment Communities: Built Environment 1 Communities: Built Environment 2 Communities: Built Environment 3 Communities: Built Environment 4 Communities: Built Environment 5 Communities: Built Environment 6 Communities: Built Environment 7 Communities: Built Environment 8 Communities: Built Environment 9 Communities: Food System Communities: Food System 1 Communities: Food System 2 Communities: Food System 3 Communities: Food System 4 Communities: Food System 5 Communities: Food System 6 Communities: Food System 7 Communities: Food System 8 Communities: Food System 9 Question Title * 3. Which of these lunch options do you prefer? Please order a lunch for me that day. It will cost $10. I will bring a lunch for myself. Please note any dietary restrictions. Question Title * 4. Please submit your RSVP for the Indiana Healthy Weight Initiative Task Force meeting. Yes, I am able to attend. No, unfortunately I am unable to attend. I am unable to attend; however the following individual will attend in my place to represent my organization/group. Name of Representative: Question Title * 5. Would you like to volunteer during the Task Force meeting e.g. helping at the registration table, coordinating lunch, distributing papers? For more details, email ahammerand@inpha.org. Yes No Maybe Done