The United Way of Metropolitan Tarrant County, the Tarrant County Public Health Department and the Fort Worth Public Health Department are leading the way in the formation of a community network to address obesity at the local level. The network will provide technical assistance and mutual support to formal and informal organizations that are ready to make healthy weight a reality for more Tarrant County residents. Through ongoing communications and opportunities for learning from each other, we intend to grow the network from 16 charter organizations to 100 organizations by the end of this year.

We invite you to be part of this network. Register your organization, company, school, faith-based group, association or any community group that can help mobilize our county around this health issue that threatens to surpass smoking as the leading cause of death in the United States.

Complete this registration form and click submit at the bottom of this form.

* = Required

Organization/Group Information Please provide the following information on your organization or group: * Organization/Group Name

* Type of Organization Select One... School Local Government Health Care Organization Faith-Based Organization Community Organization Corporation Non-Profit Organization Individual * # of Members Select One... 21-50 51-100 101-500 > 500 0-20

Please provide the contact person's information below: * Contact Person Name

* Role in Organization/Group

* Contact Phone # Fax Phone # * E-Mail Address

Street Address

City State Zip Code

Committed Actitivites Please provide the types of activities to which your organzation/group is committed: * Types of Regular Group Activities Walking Club Hiking Club Running Club Bike Club Weight Lifting Free Weights Swimming Sailing Tennis Baseball/Softball Soccer Football Jazzercise Group Dancing Other (Please comment below) Comments:

Please provide information about your individual committment below: Types of Regular Individual Activities Walking Hiking Running Biking Weight Lifting Free Weights Swimming Sailing Tennis Baseball/Softball Soccer Football Jazzercise Group Dancing Other (Please comment below) Comments:

Please provide us with information about the types of education or classes offered by your organization to the community or to employees: Types of Community or Employee or Eduction Offered Nutrition Education Brown-Bag Luncheons (Lunch 'n Learn) Yoga Pilates Other (Please comment below) Comments:

How often are you active? Select One... Daily 1 time per week 2 times per week 3 times per week 1 time per month Other (Please comment below) Comments:

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