Day of Wellness Registration

Saturday, June 21st (12:00 pm- 3:00 pm)

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Current School (if applicable)

Current Employer (if applicable)

Household Income (Your response helps us better understand the communities we serve and ensure equitable access to our programs. This information will remain confidential and is used only for internal reporting and funding purposes)

under $50,000

$50,000 – $74,999

$75,000 and above

Please indicate if your household currently receives any of the following assistance programs. Your response helps us ensure equitable access and improve our programming.

SNAP (Supplemental Nutrition Assistance Program)

WIC (Women, Infants, and Children)

TANF (Temporary Assistance for Needy Families)

SSI/SSDI (Supplemental Security Income/Social Security Disability)

Public Housing or Housing Assistance

MassHealth or other state-funded medical assistance

Unemployment Benefits

None of the above

Prefer not to say

I understand that I and/or my youth must participate in all scheduled activities—including the workout, mental health discussion, and full event experience—to be eligible for free running sneakers.

I understand that running sneakers will not be distributed to participants who leave early or skip any required part of the program.

I acknowledge that this is a wellness event designed to promote physical and mental health, and I commit to participating fully and respectfully.

I release Follow My Steps Foundation and its partners from any liability related to injuries or incidents that may occur during the event.

I give permission for photos and videos taken during the event to be used in promotional materials.

Signature

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