New York State Healthy Eating and Physical Activity Alliance

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Join the NYSHEPA Alliance

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Primary Contact
First Name*
Last Name*
Title*
Email Address*
Phone*	( ) - ext

Secondary Contact
First Name*
Last Name*
Title*
Email Address*
Phone*	( ) - ext

Organization Info
Program/Organization Name*
Organization Website*
Address 1*
Address 2
City*
State*
Zip Code*
Fax	( ) -
Your organization's venue of focus (check all that apply)	Healthcare Worksite Schools Community partnerships Government Other
Your organization's obesity-related area of focus (check all that apply)	Nutrition education Local level State level
	Nutrition policy Local level State level
	Physical activity education Local level State level
	Physical activity policy Local level State level