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New York State Healthy Eating and
Physical Activity Alliance
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Primary Contact
First Name
*
Last Name
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Title
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Email Address
*
Phone
*
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ext
Secondary Contact
First Name
*
Last Name
*
Title
*
Email Address
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Phone
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ext
Organization Info
Program/Organization Name
*
Organization Website
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Address 1
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Address 2
City
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State
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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