Employee Wellness Program

EMPLOYEE WELLNESS PROGRAM ENROLLMENT AND CONSENT

Personal Information

Full Legal Name:

Position Information

Position Start Date:   Annual Salary:

Program Selection and Participation

Select all wellness services you wish to enroll in for the program year:

Fitness classes and gym membership subsidies

Nutrition counseling and meal planning

Biometric screening (blood pressure, cholesterol, glucose)

Smoking cessation program

Mental health counseling and resilience workshops

Telehealth consults related to wellness activities

Health Information Disclosure

To tailor program services and evaluate outcomes, disclose any health conditions, physical limitations, or medications that program staff should be aware of. Disclosure is voluntary but withholding material health information may limit participation or create risk.

Emergency Contact

Employment History

Provide your two most recent employers. Employer 1:

From:   To:

Employer 2:

From:   To:

Education

References

Provide three professional references.

Legal Disclosures and Consents

At-Will Employment: Participation in the wellness program is not a term or condition of employment and does not alter the at-will employment relationship when applicable. Nothing in this form creates a promise of continued employment or modification of existing employment terms unless made in a separate signed agreement.

Equal Opportunity: Program access and any incentives are administered without regard to race, color, religion, sex, national origin, disability, age, or other protected status under applicable law. Reasonable accommodations for participation are available upon request.

Confidentiality and Use of Health Information: Biometric and health information collected through screenings, assessments, or disclosures will be treated as protected health information. Such information will be used to provide care, monitor program effectiveness, and prepare de-identified aggregate reports for program administration. Identifiable health information will not be disclosed to supervisors or third parties except as authorized below or required by law.

Assumption of Risk and Release: I acknowledge that participation in physical activity and program events involves risk of injury. I assume responsibility for my participation, confirm that I am physically able to participate or have obtained physician clearance, and release the employer, program administrators, and affiliated providers from liability for injuries arising from routine program activities, except where arising from willful misconduct.

Incentives and Tax Treatment: Any incentives, rewards, or reimbursements provided as part of the wellness program are subject to program rules and applicable tax treatment. I understand incentives may be taxable and may be subject to payroll reporting.

Data Retention and Access: Aggregate program data may be retained for program evaluation. I have the right to request access to my individually identifiable program records and to request amendment where permitted by law. Retention periods will be consistent with applicable records policies.

Authorization to Contact and Conduct Background Checks:

By checking the box below, I authorize the employer and its designated administrators to contact my previous employers listed in this form for verification of employment history and to conduct background or verification checks that are directly related to program eligibility, benefits administration, or incentive determinations. Such checks will comply with applicable law and notice requirements.

I authorize contact of previous employers and background checks as described above.

I consent to the limited sharing of my individually identifiable health information with program clinical staff and third-party service providers for the purpose of providing program services and accommodations.

Applicant Certification

I certify that all information provided on this enrollment form is true, correct and complete to the best of my knowledge. I understand that providing false, misleading, or incomplete information may result in removal from the program, forfeiture of incentives, and/or disciplinary action up to and including termination. I further certify that I have read and understand the terms, consents and releases contained in this form.

I certify that the information provided is true and complete.

Acknowledgment of Screening Procedures

For biometric screenings and clinical assessments, I agree to cooperate with screening personnel. I understand that screening results will be provided to me and used in accordance with the confidentiality provisions above. I acknowledge that I may decline any screening or assessment; however, decline may affect eligibility for certain incentives.

I consent to participate in biometric screening and clinical assessments as selected above.

Acknowledgment and Signature

By signing below I acknowledge that I have read, understand, and accept the terms of participation, consents, and releases set forth in this Employee Wellness Program Enrollment and Consent form.

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