2009 Medica Chill Out Challenge Registration Form

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* required fields.

Organization Information

*Employer group name
*Medica group number
*Contact name
*Affiliation
*Mailing address
*City
*State	Select a 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Zip
*E-mail address
*Telephone

Program Criteria

Complete the information for each of the following criteria below:

*Designated Chill Out Challenge site coordinator

*Name of coordinator Coordinator contact Information (if different from above) Address: City: State: Select a 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Email address: Telephone:

Registration Information

* Has your company participated in a Health Challenge in the past?

	Yes, the Shape Up Challenge
	Yes, another Health Challenge offered through Medica
	No, this will be our company's first challenge