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 | jane@email.com |
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?
If yes, please provide details:
2. Are you currently taking any medications or supplements? If yes, please list them.
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:
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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