Wellness Program Enrollment

Welcome to the Healthy Living Wellness Program! We are excited to have you join us on your journey to a healthier and happier life. Please complete the following enrollment form to get started.

Personal Information

Full Name	Jane Bradley
Date Of Birth	November 27, 2050
Gender	Female
Employee ID {if applicable)	14-524128
Email Address	[email protected]
Phone Number	222 555 7777

Health And Wellness Goals

Please tell us about your health and wellness goals. What do you hope to achieve through this program? (Check all that apply)

	Lose Weight
	Improve Fitness
	Manage Stress
	Enhance Nutrition
	Quit Smoking
	Improve Mental Health
	Increase Energy
	Better Sleep
	Other (please specify): ________________

Health Assessment

To help us tailor the program to your needs, please answer the following questions:

1. Do you have any existing medical conditions or allergies that we should be aware of? 

• Yes

• No

If yes, please provide details:

2. Are you currently taking any medications or supplements? If yes, please list them. 

• Yes

• No

If yes, please list them:

Program Components

Please select the wellness program components you would like to participate in. (Check all that apply)

	Fitness Classes
	Nutrition Counseling
	Stress Management Workshops
	Smoking Cessation Program
	Mental Health Support
	Sleep Improvement Program
	Health Screenings
	Employee Assistance Program (EAP)
	Other (please specify):

Privacy And Consent

I [Employee Name], understand that my participation in the program may involve the collection and use of personal health information. I consent to the collection, use, and sharing of this information for the purposes of the program. I have reviewed and agreed to the program's privacy policy and data protection practices.

[Employee Signature]

Date: [MM/DD/YYYY]

Communication Preferences

We would like to keep you informed about program updates, events, and resources. Please indicate your communication preferences:

• Email

• Phone

• Mail

Emergency Contact

In case of an emergency, please provide the name and contact information of your emergency contact:

Name
Relationship
Phone Number

Thank you for enrolling in the Healthy Living Wellness Program! We look forward to helping you achieve your health and wellness goals. Our team will be in touch with more details about your selected program components and upcoming events.

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