Qualtrics Survey | Qualtrics Experience Management

First Name

Last Name

Address. Please Include Apartment or Unit Number.

City, State, Zip Code

Home Phone Number (If applicable. If not, please write N/A)

Cell Phone Number (If applicable. If not, please write N/A)

Email (If applicable. If not, please write N/A)

How would you like to be reminded of events?

By Email
By Phone Call
Both

Is there any medical history that we should be aware of?

In case of emergency contact. Please include individual's first name, last name, contact number and relationship.

Would you be interested in receiving additional information about other programs and health topics from Stony Brook?

YES
NO

I understand that as a member of the Walking Club Program, I am participating at my own risk and I assume all responsibility for any and all damages or injuries that result from my direct or indirect participation in the Program. I understand that there are inherent risks associated with the Program that may not be presently foreseeable and hereby release Smith Haven Mall, its staff, merchants and Stony Brook University, the State of New York, its components, employees and officers from all liability for injuries arising from my participation in the Program. Further, I represent that I am in good physical condition and able to safely participate in the Program.

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