Movember Registration 2012
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1. First Name
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2. Last Name
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3. Gender
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4. Please enter your 9-digit staff ID # (found on your BruinCard):
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5. Please indicate affiliation:
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6. Department
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7. Email
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8. I plan to participate in:
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9. If your Mo wins a prize, which items would you like to receive most? (select all that apply)
10. How did you find out about the Movember event?
11. Are you currently a member of UCLA Recreation? If not check out our great packages at www.recreation.ucla.edu/newmembers
Questions 12-16 are optional, however these questions are geared toward collecting data that will help to develop and improve FITWELL Programs for Faculty and Staff. Responses are confidential and will not be shared.
12. On average, how would you describe your energy level?
Not EnergizedSlightly EnergizedSomewhat EnergizedEnergizedVery Energized
13. On average, how would you rate your ability to cope with daily stress?
Very highHighMediumLowVery low
14. Number of times you have engaged in any type of physical activity for more than 30 minutes each week for the past month? (walking, gardening, cleaning, etc.)
15. In which of the following categories would you place yourself?
16. Which of the following FITWELL programs have you participated in? Check all that apply.