Worksite on the Move Registration

If you are your team leader, please fill out this registration form with all the information about your team and about yourself as the leader implementing this program:

Team/Employer Information

Name of your team

Number of people on your team

Name of your employer

Address of your employer

Street

City*
    State*
  

Zip Code

Starting date of your program

Ending date of your program

In case your team plans on attending a walking/running race, please provide name, date and location of race

Team Leader Information

Your name

Your title at work

Your email

Your phone number

Street *

City*
    State*
  

Zip Code

Your team mates’ email addresses
Please enter all the emails of all participants in your group; their emails will be used for the pre and post evaluations for this program.


If your team does not have e-mail address, you can print the evaluations from the introductory packet, and hand it to your team for them to fill it out. Then, you will collect all filled out evaluations and mail it to: Heart of New Ulm Project, 1324 Fifth North Street, New Ulm, MN 56073

Security Question

Please answer the following security question.
What is the answer to nine + 5?