Wellness Champion Partnership Agreement Wellness Champion Partnership Agreement If you are human, leave this field blank. Champion Information Your Title (choose all that apply) * Mr. Ms. Mx. Dr. Prof. OtherOther First Name * Last Name * WUSTL Email * Birthday (mm/dd) * Department * Campus * Danforth Campus WUSM Campus North Campus West Campus Other Campus Building * I am volunteering as a Wellness Connection Champion because… * Supervisor Information Supervisor Title (choose all that apply) * 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 Wellness Connection Champion and promote a culture of wellness in my work environment. I am in good standing with the University & my department, and I’ve been in my job role for 6+ months. I have discussed this role with my supervisor and they support my participation during the workday. I understand that submission of this agreement triggers an email to my supervisor, asking them to approve my participation in the program. I give permission for Wellness Connection to use my name and image on the website and in promotional materials, and to share my demographic information within the Champion network. 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. I understand that I cannot be a Wellness Champion while I’m on leave from the University. reCAPTCHA Submit