Wellness Request / Information Form

 

Background Information

 

Company Name:
Address:
Contact:
Phone:
E-Mail:

 

Employer Information

 

Employer Size:
Gender Ratio:
Average Age:
Type of Insurance:
Self-Insured? Yes
No
Type of Work:

 

Wellness Information

 

Wellness Program in Place?
Yes
No
Wellness Coordinator?
Yes
No
Do you have an HRA?
Yes
No
If so, what kind?
Wellness Committee?
Yes
No
 
 
 
Are you interested in the following?
 
 
Lunch and Learns
Yes
No
Health Fairs
Yes
No
Wellness Coaching
Yes
No
Weight Loss
Yes
No
Diabetes Management
Yes
No
Healthy Living Kitchen
Yes
No
Budget per Person

 

Health Fair Request

 

Date of scheduled health fair:

Time of scheduled health fair:

Estimated Attendance:

Indoors or Outdoors:

Is lunch provided for vendors if event occurs through lunch?

 Yes
No

Is this the first health fair scheduled?

 Yes No

What type of screenings would you like UTMC to provide?

Any additional information:
   

Please note that requests for health fair attendance must be submitted 4-6 weeks prior to the event. (Requests will be followed-up within 2-3 business days)