Free DEPARTMENT OF HEALTH AND FAMILY SERVICES - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40097 (08/06)

STATE OF WISCONSIN Bureau of Community Health Promotion Contact: 608-266-2003

WISCONSIN NUTRITION AND PHYSICAL ACTIVITY PROGRAM STATE PLAN ENDORSEMENT
Please fax or e-mail your endorsement of the Wisconsin Nutrition and Physical Activity State Plan. Your endorsement may be publicly acknowledged on the Nutrition and Physical Activity website and in plan-related materials. Send faxes to the Nutrition and Physical Activity Program at: 608-266-3125. Or return this form by e-mail to: [email protected].

1. I am endorsing the Wisconsin Nutrition and Physical Activity State Plan as an: 2. My full name, or the name of my organization or group:

Individual

Organization

3. The type of organization I represent (choose up to three): Coalition Community Group Food Service / Restaurant Health Plan / Insurer Professional Association Recreational / Sports Setting Resident School Worksite / Employer Communication / Media Faith Community Health Care Delivery Government Agency Non-Profit Public Health Department Research Institution Retail / Business Setting University Other:

4. I will provide a link from my organization's website to the Wisconsin Nutrition and Physical Activity Program. Yes No Decision pending

5. I/we can work on the following activities in the Wisconsin Nutrition and Physical Activity State Plan to help accomplish its goals.

6. I would like to become a member of the Wisconsin Partnership of Activity and Nutrition.

Yes

No

CONTACT
Contact Name: Organization (if any): Street / PO Box: Telephone: E-mail:

INFORMATION
Credentials: Position/Title: City: Fax: Website URL: State: Zip: