Form Center

2. First Name*

   (Only your first name will be published with your story.)

3. Last Name
5. Email Address*
6. Phone Number*
8. When did your fitness journey begin?*
   When did your fitness journey begin?
10. What was your primary goal at the start of your fitness journey? *
12. What activities have you done / are doing to reach your fitness goals? *
14. What has been the biggest obstacle in reaching your goals? *
16. Which City facilities / programs have helped you the most on your fitness journey?*

    Select all that apply: 

    1. City Centre Aquatic Complex
    2. Pinetree Community Centre
    3. Poirier Sport and Leisure Complex
    4. Dogwood Pavilion
    5. Glen Pine Pavilion
    6. Group Fitness Classes
    7. Personal Training
    8. Pools / Saunas / Steamrooms
    9. Working out in our fitness centres
18. How has your life improved since you started your fitness journey*
20. What are you most proud of accomplishing since you started your journey? *
22. Were there any specific individuals who had an impact on your fitness journey?
24. What advice would you give to someone who is just starting their own fitness journey? *
26. Fill in the blank: Fitness Is _________________ *
28. Prefer to tell your story in your own words?

    If you prefer, please use this space to provide your story in your own words. Please note that all stories submitted will be subject to copyediting for grammar and Canadian Press standards.

30. Consent*

    The answers to this form will be used to create your fitness story. Do you consent to the details provided in this form (excluding your contact information) being shared on the City’s social media platforms, and on the City’s website?

    1. Yes
    2. No
32. Do you consent to your photo being shared with your story?*

    1. Yes
    2. No
34. Freedom of Information and Protection of Privacy

    By submitting this form, you are consenting to the collection, storage, use and disclosure of your personal information. The City has authority to collect, use and disclosure your information for the purposes of the City’s "Fitness Is" Campaign event in accordance with Section 26(c) of the Freedom of Information and Protection of Privacy Act. Your personal information will be disclosed to a third-party service provider (i.e. website host Civic Plus) located in Canada for the purpose of processing your request. I understand that the information provided here, and the Images, are to be used for the City’s corporate communications purposes, including the reproduction and display of the Images.  I understand that my personal information may be stored and accessible outside of Canada through the City website or on social media channels.  I understand that if I have any questions about the collection, storage, correction and/or use of my personal information I can contact the Manager Corporate Communications, 604-927-3019, 3000 Guildford Way, Coquitlam BC V3B 7N2.

Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field