Free Operations Wellness Program Enrollment Form Template
Operations Wellness Program Enrollment Form
Please take a moment to complete the enrollment form below to indicate your interest and preferences. Your participation in this program is voluntary, and all information provided will be kept confidential.
Employee Information
|
Full Name: |
[Employee's Full Name] |
|
Employee ID: |
|
|
Department: |
|
|
Position: |
|
|
Email Address: |
|
|
Phone Number: |
Health Information
Please mark all options that apply to you.
|
Existing Medical Conditions: |
|
|
|
Current Medication: |
|
|
|
Dietary Restrictions/Allergies: |
|
|
Wellness Program Preferences
Please mark all options that apply to you.
1. Fitness Goals:
|
|
|
|
|
|
2. Preferred Activities:
|
|
|
|
|
|
3. Preferred Time for Wellness Activities:
|
|
|
4. Frequency of Participation:
|
|
|
Emergency Contact Information
|
Full Name: |
[Emergency Contact's Full Name] |
|
Relationship to Employee: |
|
|
Phone Number: |
|
|
Email Address: |
Additional Comments or Questions
Please provide any additional comments or questions.
Signature:
Date:
