Register - Healthy Us Scorecard

Username

Password

Confirm Password

First Name

Last Name

Phone Ext

Fax

Full Time Employees

Part Time Employees

Company Name

This must be a physical address. no p.o. boxes or rural routes please.

Address 1

Address 2

City, State, ZIP

Website should be in http:// format.

Website

Business Type

Industry

Other

Number of Locations

Is Health Insurance Provided? (check if yes)

Disclosure: Healthy Us is being made available to all Maine businesses at no cost, through the Maine CDC Cardiovascular Health Program. I understand that my contact information will be shared with the Maine CDC CVH Program, and that they will receive aggregate reports which summarize information for all employers using Healthy Us. They WILL NOT receive individual employer information at any time. The Maine CDC Cardiovascular Health Program will use the information for the following: 1) contacting local businesses to see how they can help with worksite health promotion goals, 2) reporting progress on community-wide health efforts to state and federal grant funders, 3) leveraging current efforts to apply for new funds for continued enhancement of worksite and community health.

I agree to the above disclosure. (check if yes)