Wellness Champion Partnership Agreement

Champion Information

Your Pronouns (she/her; he/him; they/their; etc.) *

First Name *

Last Name *

WUSTL Email *

Birthday (mm/dd) *

Department *

Campus * Campus

Building *

I am volunteering as a Wellness Connection Champion because… *

How did you hear about the Wellness Champion program? *

Supervisor Information

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. *

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 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. *

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

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