SIGN UP HERE: Sturgeon Bay Program Registration and Inquiries

Register online at: https://s.zoomerang.com/r/do-goodSB

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* 1. YES! I am interested in the Do-Good Sturgeon Bay program and would like to: (please check all that apply)

Receive a follow-up call from a Bellin Health or Lakeshore CAP representative to better understand the program.

Other (please specify)

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* 2. Name of organization (i.e. company, church group, community non-profit):

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* 3. Approximate number of Door County employees and/or members.

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* 4. Contact Information:

Contact Name:

Title:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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* 5. DO-GOOD STURGEON BAY Pledge below:

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* 6. ORGANIZATION REGISTRATION FOR DO-GOOD STURGEON BAY PROGRAM:

* I understand 47% of all deaths in the United States could have been avoided by simply getting a regular physical according to the Partnership to Fight Chronic Disease and that there is an increasing need for supplemental food in Door County.
* I understand the Do-Good program supports the Lakeshore CAP Door County Food Pantry.
* I understand the Do-Good program includes a pre and post Health Risk Assessment taken 12-months apart, Individual Feedback Session, Health Coaching and 8-week Wellbeing Programs. ($500 individual value)
* I understand the program is FREE for adult employees/organization members and their spouses and adult dependents living in the Door County Area in exchange for a donation of $5 or healthy food item(s) to support the pantry. I also understand freewill offerings will be accepted throughout the year-long program.
* I understand services will be offered at Bellin Health Sturgeon Bay (former Red Owl Grocery) for smaller groups and available onsite if an organization has 15 or more participants.
* I understand my organization is responsible for assigning a Team Champion as a representative to communicate program specifics to participants and communicate a member of the Bellin Health program implementation team.
* I understand my organization will have an opportunity to be featured in social media, news stories and press releases regarding program successes and bright spots.

YES! My organization is committed to the Do-Good Sturgeon Bay program!

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* 7. YES! My organization is also interested in: (please check all that apply)

Hosting a Do-Good kickoff event for our employees/members

Participating in the Do-Good Sturgeon Bay Advisory Committee

Hosting a Do-Good community wellbeing program or event

Matching funds or making a donation to the Lakeshore CAP Door County Food Pantry

Volunteering at the Lakeshore CAP Door County Food Pantry

Other (please specify)

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* 8. Team Champion Contact Information:

Name:

Email Address:

Phone Number:

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* 9. Please confirm: YES! I have spoken with leadership at my organization and they support our commitment to the Do-Good Sturgeon Bay program:

Organization Leader's Name:

Title:

Email Address:

Phone Number:

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* 10. Does your organization offer a group health plan to its employees/members?

YES

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* 11. If you answered, YES to the above question, please provide contact information for the individual at your organization who is responsible for your group health plan.

Name:

Email Address:

Phone Number:

CONGRATULATIONS and THANK YOU for your registration and comments. A representative from Bellin Health will contact you shortly to confirm your registration and answer your questions. In the meantime, please join us on Facebook at https://www.facebook.com/dogoodsturgeonBay/