Group Team Request


Please complete the form below to request information for a company or group program or click here to send in the administrator form for your company. After you submit the form, you will be contacted by a representative of Live Healthy America to answer any questions and explain the next step in setting up your company or group program.

If you are trying to register your team, do NOT fill out this form.  Enter your GROUP ID at the top of the screen to be taken to the registration page for your company/group.

Live Healthy America Overview, click here.




* indicates required fields

Company/Group Name *:
Contact Person's Information:
First name *:
Last name *:
Position:
Email *:
Phone:
Preferred Contact Method *:
Company/Group Information:
Address 1 *:
Address 2:
City *:
State *:
Postal Zip Code *:
State where group, or company's main office, is located *:
Are there offices in multiple states? (is this a multi-state group?) *
How many employees are in your company? *:
How did you hear about us?:


 

 

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