Find Your Match

Name*

First Last

Your Humana Associate ID Number (AIN)*

Humana Email Address*

Note: Emails will come from take10foryourself.com.You may unsubscribe anytime.

Do you currently have a match?*

No, please match me
No, but I would like to update my match criteria
Yes, but I need a new match
There is a specific person I would like to be matched with

Reason for new match*

Current match has left Humana or is no longer interested
No one responds from match email
I prefer to be matched with someone different

Your Buddy's Info

Buddy's Name

First Last

Buddy's Email Address

You must check this statement in order to continue with your selected buddy*

I have spoken with this person and we both agree that we want to be each other’s buddy. This person has agreed to complete the enrollment form and list me as a buddy.

Location & Matching Criteria

In which country do you reside?*

USA
India
Philippines

ZIP Code*

TimeZone*

Eastern
Central
Mountain
Pacific

Your Gender*

Male
Female

Would you like to be matched with someone of the same gender?*

Prefer same gender
Prefer different gender
Don't care

What are your personal goals for this program?*

Select all that apply.

Increased support and accountability for my health and well-being goals
Increased success in achieving my health and well-being goals
Increased sense of connection and community in the workplace environment
Other

You selected "Other", what is your personal goal for this program?*

What are your objectives for you and your Take 10 Friend*

Select up to 3

You selected "Other", what is another objective for you and your Take 10 Friend?*

Is it important to you to be in the same area (15-mile radius) so that you can meet in person to work on your goals and objectives?*

Yes, this is important to me
My Take 10 Friend can be anywhere in the U.S. We’ll communicate in other ways.
My Take 10 Friend can be anywhere in the world

Hidden

Would you like to be matched with someone who works out in the same Humana fitness center?

Yes
No

Select your preferred fitness location

Clocktower (Louisville), KY
Data Center (Louisville), KY
The Forum (Louisville), KY
Glendale, AZ
Green Bay, WI
Miramar, FL
San Antonio, TX
Springdale, OH
Wel at Humana (Louisville), KY

Is it important to you that your match is in the same country as you?

Yes, this is important to me
My Take 10 Friend can be anywhere in the world

How would you describe your current level of well-being?*

I’m very dissatisfied with my overall well-being
I’m dissatisfied with my overall well-being
I’m neither satisfied nor dissatisfied with my overall well-being
I’m satisfied with my overall well-being
I’m very satisfied with my overall well-being

If you’ve participated in Take 10 for Yourself in the past, how frequently do you participate?*

Daily
2-4 times per week
1-2 times per week
I don’t participate in Take 10 for Yourself

With whom do you Take 10 on a regular basis?*

Friends/colleagues at work
During work meetings/calls
Friends outside of the workplace
Family
I don’t Take 10 with others

How likely would you be to regularly participate in Take 10 for Yourself if each of the following activities were offered:*

Terms & Conditions*

I have read and accepted the Terms and Conditions for this text/email program.

Hidden

Reminders

Hidden

Date

Hidden

Passthrough Token (HIDDEN

	Less Likely	More Likely
Work-at-home and travel exercises
Tips for healthier eating
Exercise and tips to reduce stress
High energy/cardio breaks
Mindfulness and meditation

TAKE 10 WITH A FRIEND

FIND YOUR MATCH

Your Buddy's Info

Location & Matching Criteria