Wellness Champion Approval Form

Congratulations! You have been selected as a Wellness Champion for EKU’s employee wellness program. Please complete this approval form along with your manager and return it to the Employee Wellness office in Jones 106 (mailing address Coates CPO 24A) or scan to HealthyYou@eku.edu.

Wellness Champion Information

Name________________________________________________________________________

Department_______________________________ Phone Extension____________________

Work Email Address__________________________________________________________

I have read the Wellness Champion Role document and agree to fulfill the responsibilities of this position. (____) YES (____) NO

Supervisor/Manager InformationYour immediate supervisor/manager _____________________________________________

Manager’s email address_______________________________________________________

Supervisor/Manager Approval

Do you give permission for this employee to serve as a Wellness Champion for the employee wellness program (____) YES (____) NO

I have read the Wellness Champion Role document and have a clear understanding of this volunteer position. (____) YES (____) NO

Manager Signature:___________________________________________ Date:

Wellness Champion Signature:___________________________________ Date: __________