Name (First)
*
Name (Last)
*
Date of Birth
*
Email
*
Phone Number
*
Address
*
County
*
Adams
Franklin
Lancaster
Lebanon
York
Other
If Other, please enter your county
Is where you live more urban (city), suburban or rural?
*
Urban (City)
Suburban
Rural
Gender
*
Male
Female
Non-Binary
Unknown
Race/Ethnicity
*
Select All That Apply
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern
Native Hawaiian or Pacific Islander
White
Other
Other Race/Ethnicity
How did you hear about Winter STREAK?
*
Select All That Apply
Social Media (Facebook, Instagram, X, etc.)
Friend/Family Member
Newspaper
WellSpan Health Website
Physician/Provider Office
MyWellSpan Portal
Emails
WellSpan Yammer/INET
Winter STREAK Website
Winter STREAK Email
Employer
Other
Other (Not Listed Above)
Want more information on local events and initiatives? Considering joining one of our health coalition email distribution lists below!
Adams County
Franklin County
Lebanon County
York County
Captcha
*