Champion Partnership Agreement Form Wellness Champion Partnership Agreement 2023 Champion Information Your Title (choose all that apply) Mr. Ms. Mx. Dr. Prof. OtherOther Your Pronouns First Name * Last Name * WUSTL Email * I am volunteering to be a Wellness Champion because… * How did you hear about the Wellness Champion program? * Supervisor Information Supervisor Title Mr. Ms. Mx. Dr. Prof. OtherOther Supervisor First Name * Supervisor Last Name * Supervisor Email * Agreements: Please check the boxes to verify your eligibility. I agree to be a WashU Wellness Champion and promote a culture of wellness in my work environment. * Yes, I agree I am in good standing with the university & my department, and I’ve been in my job role for 6+ months. * Yes, I agree I have discussed this role with my supervisor and they support my participation during the workday. * Yes, I agree I understand that submission of this agreement triggers an email to my supervisor, asking them to approve my participation in the program. * Yes, I agree I give permission for WashU Well-being to use my name and image on the website and in promotional materials, and to share my demographic information within the Champion network. * Yes, I agree If I am no longer able to serve in this role, I will do my best to find a co-worker who could fulfill this role for our department. * Yes, I agree I understand that I cannot be a Wellness Champion while I’m on leave from the university. * Yes, I agree reCAPTCHA Submit If you are human, leave this field blank. Δ