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2. Name*
3. Email Address*
5. Organization/Agency (if applicable)
6. Title/Role (if applicable)
8. Which best describes you? (Select all that apply)*

   1. Resident
   2. Local business owner
   3. Faith-based organization
   4. School or youth representative
   5. Nonprofit or community organization
   6. Healthcare professional
   7. Municipal employee or official
   8. Other
10. How would you like to contribute to the Mayor’s Wellness Campaign Coalition? (Select all that apply)*

    1. Attend coalition meetings
    2. Provide input or ideas
    3. Assist with planning events or programs
    4. Volunteer at community events
    5. Serve as a community ambassador or spokesperson
    6. Offer professional expertise (e.g., nutrition, mental health, fitness)
    7. Other
12. What health and wellness topics are most important to you? (physical activity, mental health, disease prevention, etc.)
14. What types of programs, resources, or events would you like to see the coalition develop?
16. Would you like to receive the RockawayConnect newsletter with health tips, community resources, and updates on upcoming Mayor’s Wellness Campaign events?

    1. Yes, please add me to the mailing list
    2. No, thank you
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20. 1. Receive an email copy of this form.
21. Email address

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22. Submit

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