The Coda Jazz Fund

Name: Email: Phone:

The CODA Jazz Fund will hold a Health and Financial Fitness Fair on Saturday, October 11, 2008, in conjunction with The American Jazz Museum Salutes Art Blakey. We are conducting a survey to prepare for the fair.

1. Do you have health concerns?

Yes No

2. Do you have health insurance?

Yes No

3. Do you have a retirement plan?

Yes No

4. Do you have a primary care physician?

Yes No

5. Do you have a financial advisor?

Yes No

6. Do you get annual or routine health physicals?

Yes No

If no, what prevents you from getting routine health care?

Do not have insurance	Medications too expensive
Transportation issues	Other

7. Would you attend a Health and Financial Fitness Fair October 11, 2008, 10 am-2 pm?

Yes No

8. What are your top 3 concerns about your health?

9. Would you benefit from more financial knowledge regarding taxes, saving
money, or insurance?

Yes No

10. Do you need transportation to the Health Fair?

Yes No

The screenings will last approximately 45 minutes—1 hour. Check time you would prefer to attend the Health and Financial Fitness Fair:

10-11 am 11-12 noon 12-1 pm 1-2 pm

If you have questions, please call: 816-234-4417

WE HOPE TO SEE YOU AT THE FAIR BECAUSE CODA CARES ABOUT YOU.