Mayors Wellness Campaign 2023 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. You can use this document to do so.

Once you have submitted your application, you will receive a confirmation email.

Municipality (Official Name)(Required)
County(Required)
Population Size(Required)
Mayor's Name(Required)
First Last
Mayor's Email(Required)
Mayor's Phone Number(Required)
Secondary Contact Person's Name(Required)
First Last
Secondary Contact Person's Role(Required)
Secondary 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. 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”.
2. What are the top 3 areas of health and wellness that are of greatest concern to your community? How did you identify these areas of health and wellness?(Required)
3. 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.)
4. Does your committee have diverse representation that reflects the demographics of your community? Describe.(Required)
5. 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.
6. 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”.
7. Describe how your MWC activities are funded.(Required)
Provide details on whether programs are run by municipal staff or volunteers.
8. How does your MWC address the specific health needs of underserved residents in your community?(Required)
The term “underserved communities” refers to populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life, as exemplified by the list in the following definition of “equity.” The term “equity” means the consistent and systematic fair, just, and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.
9. Approximately how many people participated in MWC programs in 2023?(Required)
10. Describe how you evaluated the effectiveness of your activities and programs.(Required)
(No more than 500 words.)
11. What feedback did you receive from your evaluation(s)? How did you utilize this feedback?(Required)
(No more than 500 words.)
12. Please feel free to attach any surveys or other evaluation tools here.
Drop files here or

Max. file size: 50 MB.
13. What are the future goals of your MWC? What areas of health and wellness do you plan to address in 2024?(Required)
(No more than 250 words)
14. Please note any successful programs or initiatives your MWC engaged in that you would recommend to other municipalities.(Required)
15. 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)
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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