The information you provide is strictly confidential. Data will be stored in such a way that only you will be able to see your entries. Individual participants will not be identifiable by name. Only group characteristics and results will be reported.
FIRST NAME

LAST NAME
Street address
City, State ZIP
Library name

Email address



Month, date and year of birth as mm/dd/yy
  Age
GENDER
Female Male


ETHNICITY (please select one)
White/Non-Hispanic Black/Non-Hispanic Hispanic
Asian Native American Other
Prefer Not to Answer
1. ADULTS: How many days a week do you currently engage in moderate physical activity (e.g., brisk walking, bicycling) for at least 30 minutes?
None 1 2 3 4 5 6 7

CHILDREN (18 or younger): How many days a week do you currently engage in moderate physical activity (e.g., brisk walking, bicycling) for at least 60 minutes?
None 1 2 3 4 5 6 7

2. Are you currently at a healthy weight? Yes No

3. Do you have your own library card? Yes   No

4. How often do you visit the library?
Weekly   Monthly   Once or twice a year

5. How many library programs have you attended in the past 3 months?
None 1 2 3 4 5 or more

Click submit to complete your registration.