Physical Activity Submission Log
First day of week reporting
*
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Month
-
Day
Year
Date Picker Icon
Last day of week reporting
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Full name
*
First Name
Last Name
Address
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email address
*
Email
Did you attend any free fitness classes with Move More Eat Healthy?
*
Yes
No
Did you meet your the two and a half hours of physical activity a week for adults?
*
Yes
No
Partially
Did you experience any problems or issues that kept you from being physically active?
What types of physical activity did you do?
Walking
Running
Biking
Swimming
Zumba
Other
How many total steps did you complete this week?
Attach file or document (i.e fitness log, screen shot of fitness app log)
Upload a File
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What can Move More Eat Healthy do to help you reach your fitness goals?
Are there any other fitness classes you would like to see near you?
Have you pledged to Move More this Summer 2019 yet, and promised to get two and a half hours of physical activity a week for adults?
Yes
No
Submit
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