Membership Application

Membership Type: First Name: Last Name: Email: Home Phone: Home Address: City: State: 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 American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Referred by (please share name of individual or organization, if applicable): Gender: Female Male Non-Binary Birth Date: / / Ethnicity: Household Size: Annual Household Income: What is your most common mode of transportation? How far is the nearest grocery store from your home? How far is the nearest gym/fitness center from your home? How often do you exercise in your home or neighborhood? What do you find are your biggest challenges to exercising? Have you set health goals for yourself? Is there anything else you want to share with us?