Name

Facility Name

Email Address

Exercise (must have 3): Exercise (must have 3): Go on a walk daily Go on a run daily Hike regularly Bike regularly Play an active sport regularly Go to the gym at least twice a week Attend an instructed fitness class at least once a week Attend an instructed yoga class at least once a week Attend a dance class regularly Do at home workouts at least twice a week

Food (Required): Food (Required): Swap unhealthy snacks for healthier snacks Swap high sugar drinks for water Try a new healthy recipe at least once a week (see Healthy Kingsport's website/Facebook for details)

Tobacco (Required) Tobacco (Required) Tobacco-Free Vape-Free