Group ID Request Form

Live Healthy Iowa

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GROUP ID REQUEST FORM

Thank you for your interest in organizing a Live Healthy Iowa (LHI) challenge within your business, community or organization! Please complete this form and upon submission a LHI team member will be in contact with you.

Company/Organization:

Eligible Population::

(Total # of people invited to register with your Group ID)

Contact Name::

Title::

Phone::

Fax::

Email::

County::

Preferred Method of Contact::

Payment Method::

*If the company/organization elects to pay for all or a portion of the registration fee, an invoice will be sent to the contact above after registration closes on February 15, 2015.

Other amount:

Department/Location List::

Yes No

Would you like to organize participants by department or location?

*If yes, your LHI account representative will contact you to obtain the list

Employee ID::

Yes No

Do you need to collect Employee ID # to confirm participants are employees of your company?

Logo::

Yes No

Would you like to add your organization's logo to the LHI website?

Marketing Materials::

Please mark the materials you would like to receive and indicate the quanity. The pdf versions of these materials are available in the toolkit on the Administrator dashboard, accessible after account set-up.

Statement of Confidentiality::

By selecting the confidentiality box, I agree to keep participant information confidential and not use privileged information in any way other than the encouragement and promotion of the Live Healthy Iowa 10 Week Wellness Challenge.

Other 2016 Challenges::

Please check the boxes below if you would like to create your group ID for other challenges in 2016. Your LHI representative will contact you regarding the payment method for each individual challenge.

Please wait...

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Questions? Contact us, we're happy to help!
888.777.8881
info@livehealthyiowa.org

Proud Live Healthy Iowa Sponsors