Activity Report Self-Assessment

Thank you for taking a few moments to complete and submit this activity report. Your feedback is necessary to evaluate how this program is performing and will help determine and guide its future.

Name*
First Last
Facility Name or Place of Activity:*
Please indicate the day(s) and month(s) on which you participated in the activity/s. Include a description of the activity and the duration for which it was performed (e.g. July 1st- FES Cycling for a 45 minute period).*
Please provide a short assessment of your progress or benefits received through your wellness pursuits.*
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