Business Membership Application

NOTE: All fields are required. Otherwise the application cannot be processed.

Business Name: Business Mailing Address:
Contact Person: City
Email Address: State:
Phone Number: ZIP Code:
Number of Employees: Type of Business/Industry:
1. Is your business a "Certified Healthy Business"? Yes No
2. Have you provided free advertisement/advertising space, or healthy community information for the Healthy Community coalition at your business? Yes No
3. Is your business a tobacco-free workplace? Yes No
4. Do you offer blood pressure screenings to your employees and patrons on a regular basis (at least annually)? Yes No
5. Do you offer or support an incentive or challenge program for weight control to your employees? Yes No
6. Do you offer or support an activity or walking program to your employees? Yes No
7. Must answer yes to 7A or 7B to acquire points.    
  A. If you are a restaurant or have a cafeteria/deli at your place of business, do you offer and indicate at least 10% of your menu items as healthy options? Yes No
  B. If you have vending machines or provide snacks at your place of business, do you offer healthy options (lowfat options, fruit, water, low calorie options)? Yes No
8. Do you provide a link on your business website to the Healthy Community website or provide Healthy Community brochures to your employees if you do not have a website? Yes No
9. Do you promote healthy lifestyles to your employees through training or awareness opportunities? Yes No
  If yes, how?    
 

Pledge:
By submitting this application you pledge to actively help Norman Oklahoma become a Healthy Community by taking positive daily steps to improve my/our health in the following areas:


Hypertension
Obesity/Overweight
Smoking
Lack of Physical Exercise


Please send one complimentary item checked below and two "We Support Healthy Community" window stickers.
T-Shirt
Lapel Pin		 Ink Pen
Poster
 
Check if you would like to be contacted to order additional items.
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