Young People Healthy Heart

On The Move Registration Form

It's for Everyone in 2013!

On The Move Goals Plus - includes incentive gifts & classes, newsletters, email, website participation, cost $12 for individuals & $35 for families* On The Move Goals - No Charge - newsletters, email, website participation only

My Exercise Goal - Everyone sets physical activity goal

I am currently doing minutes of physical activity a week.

My exercise goal is minutes of physical activity a week.

Describe what you plan to do:

Contact Information

Name

Address

City

State

Zip

Phone

Do you prefer internet communication? ex. email, website

Yes No

Do you want your newsletters mailed via US Postal Service?

Yes No

Waiver In consideration of your accepting this entry, I hereby, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against the organizations holding this event, their agents, representatives, successors and assignees, for any and all injuries sustained by me at said event. Clicking submit indicates that you agree.

I do not want my picture to appear in any on the move publications, including website, poster & news print. If I don't check this box on the move may use your picture in the above media.

Sponsored by the Barnes on the move Partnership
American Heart Assn.
North Dakota Cancer Coalition

Cost: $0