Mayors Wellness Campaign 2022 Healthy Town Application

Thank you for your time and dedication to your local Mayors Wellness Campaign (MWC), and for applying for the New Jersey Healthy Town designation. For more information regarding the MWC or your application, please contact Julie DeSimone at jdesimone@njhcqi.org or 609-452-5980.

We highly recommend using a word document to complete your answers and copying and pasting your final responses in the fields below.

Municipality (Official Name)(Required)
County(Required)
Population Size(Required)
Mayor's Name(Required)
First Last
Mayor's Email(Required)
Mayor's Phone Number(Required)
Additional Contact Person's Name(Required)
First Last
Additional Contact Person's Role(Required)
Additional Contact Person's Email(Required)
Municipal Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Latest Date MWC Participation Pledge was signed(Required)
Social Media Information(Required)
Respond "N/A" if you do not utilize these platforms
Facebook Twitter Instagram Municipal Website
1. Describe your community’s demographics. This should include updated Census information including but not limited to population, age, race, and median income.(Required)
2. The MWC recommends completing a local needs assessment to get the facts about your town’s health to ensure that your programming addresses the greatest health needs and challenges in your community. Describe your town’s process for collecting facts and information about community needs.(Required)
If you do not complete a needs assessment, please respond “N/A”.
3. What are the top 3 areas of health and wellness that are of greatest concern to your community?(Required)
4. Describe the overall goal of your MWC programming.(Required)
For example, is the goal to increase resident access to physical activity opportunities? Is the goal to provide community health education?
5. Describe the members of your MWC Committee and how they collaborate to create town programming. Include whether any residents serve on your MWC Committee and how often your committee meets.(Required)
If you do not have a MWC committee, please respond “N/A”. (No more than 100 words.)
6. Use the MWC Activity Form to provide information about up to 10 of your activities:(Required)
If a category does not apply to your event, respond “N/A”. Download the MWC Activities form here: https://njhcqi.info/MWCHTAppExcel2022
Max. file size: 50 MB.
7. Which programs were based off the MWC Toolkit, MWC Handbook, or another resource provided to you by the Quality Institute? Please list.(Required)
If none, respond “N/A”.
8. Describe how your MWC programs were promoted. Indicate if you connect your local program back to the Quality Institute program on any of your promotional information or website.(Required)
(No more than 150 words.)
9. Describe how your MWC activities are funded.(Required)
Provide details on whether programs are run by municipal staff or volunteers.
10. Approximately how many people participated in MWC programs in 2022.(Required)
11. Did you evaluate the effectiveness of your MWC programs? Describe your evaluation process. What feedback did you receive from your evaluation(s)? How did you utilize this feedback?(Required)
(No more than 500 words.)
Please feel free to attach any surveys or other evaluation tools here.
Drop files here or

Max. file size: 50 MB.
12. What are the future goals of your MWC? What areas of health and wellness do you plan to address in 2023?(Required)
(No more than 250 words)
13. Please note any successful programs or initiatives your MWC engaged in that you would recommend to other municipalities.(Required)
14. What would you like to see from us (specific tools, more resources, policy briefs, speakers, connections to other towns/state leaders/health experts, health topic information)? Do you have any suggestions?(Required)
15. Optional: Attach up to five additional documents that you feel would supplement your application
Examples include flyers, pictures, testimonials from residents etc.
Drop files here or

Max. file size: 50 MB, Max. files: 5.
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