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Walk Norfolk Health & History Tours

2. Application for the Health, History & Habitat Tour

4. NO LONGER ACCEPTING REGISTRATIONS!
   We are so sorry, but response for this Sunday’s October 16, 2016 Health, History & Habitat Tour has been overwhelming! We can no longer accept online or onsite registrations. But stay tuned! We will have many walks coming up in the near future. Much Thanks!

6. First Name

7. Last Name

8. Date of Birth

10. Phone

11. Email Address

13. Address1

15. City

16. State

17. Zip

19. Gender

    1. Male
    2. Female

20. Ethnicity

    1. African American
    2. Asian
    3. Native American

    1. Pacific Islander
    2. White

22. Height

23. Weight

25. Blood Pressure (if known)

26. Cholesterol Levels (if known)

27. Blood Sugar Level (if known)

29. How Many Hours Do You Exercise a Week? (hh:mm)

31. Do You Smoke?

    1. Yes
    2. No

32. How Many Cigarettes Daily?

34. Will You Be Participating in the Health, History & Habitat Tour walk on October 16, 2016, at 2:00 p.m.?

    1. Yes
    2. No
    3. Maybe

36. If You Are the Parent or Legal Custodian of a Minor (listed above) Registering for the Walk Norfolk Historic Tour Campaign, Does He/She have Your Permission to Participate?

    1. Yes
    2. No

38. Do You Have a Personal Goal (e.g., distance walked, weight loss, improved health status, etc.) that You Wish to Accomplish via Your Participation in the Walk Norfolk Health & History Tours campaign?

40. Do You Voluntarily Participate in the Walk Norfolk Health & History Tours campaign and Agree to Hold Harmless the Virginia Department of Health, the City of Norfolk, and the Virginia Zoological Park from Any Liability from Any Injury You Sustained from Your Voluntary Participation, Including Your Minor Child?

    1. Yes
    2. No

42. Last Doctor's Visit
    Last Doctor's Visit

43. Last Complete Physical Exam
    Last Complete Physical Exam

45. Emergency Contact

47. First Name

48. Last Name

50. Emergency Contact Relationship

51. Emergency Contact Telephone

53. Signature

Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

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