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Please enter your personal information:
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Email:
Age:
Gender:
Ethnicity:
Complete this section only if you are participating as part of a group - enter 1 group only. [Individuals may skip this section.]
School:
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Please answer the following questions:

On average, how many days per week do you engage in at least 20 minutes of exercise that increases your heart rate and makes you sweat?

What type of medal do you hope to achieve?

If you have not been physically active (i.e. you have not exercised 20 minutes or more a day three or more days a week), we recommend you work for a bronze medal. If you've been moderately active or engage in regular, sustained exercise, then we recommend working toward a silver or gold medal.
Would you be willing to participate in a brief follow-up telephone survey related to the Lt. Governor's Challenge?

Would you be interested in volunteering to help with the Lt. Governor's Challenge?
Please select a username and password:
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