Wufoo

Your Name * First Last
Your Email *
CITY, STATE: We are building a movement of health-conscious Black women across the country. Knowing which communities are represented helps us to decide how we allocate resources. *
SET YOUR GOAL: Which of the following healthy activities will you do?
[Choose One] *
SUCCESS: Complete this sentence, "I will know that I am successful when...(enter a specific EVENT or certain NUMBER) Examples: I will do the Panama City Triathlon (EVENT) or 15 yoga classes (NUMBER) *
DEADLINE: What is your timeline for reaching your goal? Your deadline should be no more than 6 months from today! * MM / DD / YYYY
REWARD: When you succeed, how will you reward yourself?
[Optional, Next Level!] SMILE! Share a sunny picture of yourself. Go ahead, we'll wait. Cheese!!!! Upload it here.
[Optional Support] BUDDY SYSTEM: Share YOUR phone number ONLY if you would like to be paired with a Healthy Role Model Buddy. ### - ### - ####
Please note that you will qualify as a Healthy Role Model and receive your special edition GirlTrek t-shirt after you complete your goal. To confirm completion, you must send a picture in action - doing whatever your goal is - to info@girltrek.org. Please write this email address down and post it on your refrigerator! Pinky promise? *
Yes, I will email an action shoot to confirm that I've completed my goal!
Do Not Fill This Out