Champion Partnership Agreement Form Wellness Champion Partnership Agreement Champion Information Your Title (choose all that apply) Mr. Ms. Mx. Dr. Prof. OtherOther Your Pronouns (she/her; he/him; they/their; etc.) * First Name * Last Name * WUSTL Email * Birthday (mm/dd) * Race (check all that apply) American Indian or Alaskan Native Asian Black/African American Native Hawaiian or Other Pacific Islander White/Caucasian Prefer not to say OtherOther Campus * Danforth Campus WUSM Campus North Campus West Campus Other Campus Department * School * Arts and Sciences Brown School McKelvey School of Engineering Olin Business School Sam Fox School of Design and Visual Arts School of Law School of Medicine University College Central Fiscal Unit Other School Building * I am volunteering as a Wellness Connection 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 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 reCAPTCHA If you are human, leave this field blank. Submit