First Name: Last Name:

Address: City:

County: Autauga Baine Baker Baldwin Barbour Benton Bibb Blount Bullock Butler Cahawba Calhoun Chambers Cherokee Chilton Choctaw Clarke Clay Cleburne Coffee Colbert Conecuh Convington Coosa Cotaco Crenshaw Cullman Dale Dallas Decatur Dekalb Elmore Escambia Etowah Fayette Franklin Geneva Greene Hale Hancock Henry Houston Jackson Jefferson Jones Lamber Lauderdale Lawrence Lee Limestone Lowndes Macon Madison Marengo Marion Marshall Mobile Monnore Montgomery Morgan Perry Pickens Pike Randolph Russell Sanford Shelby St.Clair Sumter Talladega Tallapoosa Tuscaloosa Walker Washington Wilcox Winston Zip:   Location: Urban Rural

Date of Birth (YYYYMMDD): Ethnicity: African-American Asian Caucasian Hispanic Native American Other   Gender: Male Female

Email: Username: Password:

I wish to participate voluntarily in Alabama In Motion. I agree to accept full responsibility for any injuries while participating in this program. I agree to check with my doctor before I start if I have any physical conditions or problems that might require special attention and/or if I am a male over 45 years old or a female over 50 years old.
Yes No

How many days a week do you preform the following activities?
A. Walk: B. Run: C. Swim: D. Ride Bike: E. Other:

How many hours a day do you preform the following activities?
A. Walk: B. Run: C. Swim: D. Ride Bike: E. Other: