Employee Wellness Program Sign-up

Personal Information

Name:

Title:

Division:

Office:

Phone:

Email:

Wellness Information

Please select those that apply to you:

Current Workout

I will most likely use:

I am interested in:
Yoga/Pilates
Karate Fitness
Dance
Other:

I primarily work in:
Albany Troy

I will most likely work out:

I am concerned about:
Weight
Diet
Overall Fitness

Other Concerns/Questions/Comments:

Did another employee encourage you to sign-up? If yes, who?

I have decided to participate in The Sage Colleges Employee Wellness Program, I understand that in doing so I am committing to helping myself live a healthier lifestyle.

I choose to participate in:
Choose one or both
Track 1 : more information
Track 2 : more information

I understand that my participation is completely voluntary and promise to provide accurate information regarding activities I participate in as well as any problems I may encounter. I also understand that aspects of the program may change at any time as the program continues to evolve.

By checking this box I electronically sign this contract and agree to the above information.