STEPS Registration Form
Name: (First)
(Last)
Email:
Phone:
User ID:
(6 - 20 characters, letters and numbers only)
Password:
(6 - 20 characters, letters and numbers only)
Retype Password:
Are you a member of a currently registered team?
No
Yes
If yes, which team?
Edgewood Elementary
George D. Lisby Elementary
Jarrettsville Elementary
Sex:
Male
Female
Age:
Height:
4
5
6
7
Feet
01
02
03
04
05
06
07
08
09
10
11
12
inches
Weight:
lbs.
Ethnicity:
Select
African American
Hispanic
Asian/Pacific Islander
American Indian/Alaskan Native
White, Non-Hispanic
Biracial
Other
Average number of days per week you are physically active:
(includes daily activities as well as fitness exercise)
Select
0
1
2
3
4
5
6
7
Days
Average minutes of physical activity per day that you are physically active:
Select
0
1 - 15
16 - 30
31 - 45
45 - 60
60 more more
Minutes
Average intensity of physical activity:
Select
None
Light
Moderate
Vigorous
What most prevents you from being more physically active:
Select
I am physically active 5 - 7 days/week
I don't have enough time
Lack of access to recreation areas such as walking/bike trails
I have physical/medical restrictions
Cost
I am too tired
Other
