Just Walk Registration - Just Walk WorcesterJust Walk Worcester

Date:*

Name:*

First Last

Email:*

Address:*

Street Address Address Line 2 City State ZIP Code

Phone:*

Sweatshirt Size:*

Do you wish to be publicly recognized for your accomplishments in the Just Walk Program?*

Yes, I wish to be publicly recognized.
No, I do not wish to be publicly recognized.

How did you find out about the Just Walk Program?*

Other

Please complete the following questions about your physical activity over the previous three months.

Select what best describes you next to each question. The following three questions are required fields to submit.

How often do you exercise?*

Less than once per month
A few times per month
1-2 times per week
3-4 times per week
5-7 times per week

What type of exercise (s) do you usually do?*

Activities of Daily Living- (walking the dog, light gardening, normal walking, shopping, cleaning)
Light Aerobic Activity-(brisk walking, golfing, hiking, pool aerobics)
Moderate Aerobic Activity (speed walking, light jogging, light weight lifting, casual biking, tennis)
Intense Aerobic Activity (mountain biking, college athlete, running)
Competitive Athlete (sprinting, speed swimming, distance cycling)

When you exercise, how long do you usually exercise at each session?*

Less than 10 minutes
10-20 minutes
20-30 minutes
More than 30 minutes

PC & Mac Users Please hold down your left mouse button as you sign your name. If you need to put your First and Last Name on two different lines, simply release the left mouse button and then click in the box again to sign your Last Name. You can also click on the refresh button in the lower left hand corner to "erase" your signature and start over.

Mobile & Tablet Users You can use your finger or stylus to write your signature.

Signature:*

I understand that I must be a Worcester County resident or employee to participate in the "Just Walk" program.

I voluntarily choose to participate in the “Just Walk” program sponsored by the Worcester County Health Department.

I have been informed and understand that the “Just Walk” program is designed to place a gradually increasing workload on my circulatory system in an attempt to improve its functioning. If, at any time during my participation in the “Just Walk” program, I experience any form of chest pain, pain in the extremities, discomfort, dizziness, fainting, or other similar symptoms, I will discontinue participation in the program and consult with a physician.

I am fully aware, understand and accept the risks involved, which I have had explained to me, in participating in this program. I agree to release and exculpate the Worcester County Health Department and its employees and representatives from any liability to me for any damages caused by the ordinary negligence of either party, including negligence related to the condition of maintenance of the property over which the program will occur and any other negligence expressed or implied in law, statue, regulation or public policy. I also expressly waive any claim against the Worcester County Health Department for damages founded on any other legal theory.

I have read and understand the foregoing statements. Any questions which have arisen or occurred to me have been answered to my satisfaction. None of the answers provided to me orally have been in any manner inconsistent with the information provided in this statement.

Comments / Questions:

Name

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