Please complete the following form and fax it to us at 203.975.9078 to receive more information and find out if your facility qualifies for this program.
(Items in red are required fields)
Name
:
Title
:
Alternate Contact Name:
Title:
Facility Name
:
Department:
Facility Street Address (no PO boxes please)
:
City
:
State
:
Zip
:
Phone
:
Fax:
Email
:
Facility Website Address if applicable:
What is the best way to reach you
:
Phone
Fax
Email
Regular mail
Your Facility Information:
Year Facility Opened
:
Number of Members
:
Total Size (sq. ft.)
:
Average Member Age
:
Estimate % of members age 35+
:
Estimate % of members age 50+
:
Hospital of Clinical Affiliation
:
Yes [Name]:
No
Programs Your Facility Currently Offers Members (check all that apply)
:
Brochure Distribution Center
Education Seminars
Health Resource Library
Cardio-Pulmonary Center
Free Product Samples
Health Risk Assessments
Diabetes Education
Health Education Literature
Health Screenings
Personal Training
Wall Magazine Program
Weight Management
Please print this form and fax it to us at 203.975.9078
