Governor's Healthy Ohioans Active Lifestyle Award

If you are an Ohioan who has received a Presidential Champion or Active Lifestyle Award, and would like to receive the Governor's Healthy Ohioans Active Lifestyle award, please complete the following form:

Fields in Boldface indicate required fields.

Name:
 

Employer:
 

Home Address:

          City:

        State:         Zip:
 

Email:
 

Phone:

 ( ) - -
 

Dates of Physical Activity:

  from / / to / /

Date you earned your Presidential Champion or Active Lifestyle Award:

  

  / /

     
           
 
Last Updated: 8/22/03

Home | Contact Us | Privacy Policy