2019 Holiday Challenge

Electronic payroll deduction and order form (payroll deduction for Crouse/CMP employees only)

Just weigh in twice….once before and once after the holiday season

Your weight will be kept confidential and only used for the purpose of program administration

How it Works:
Each participant contributes $20 to “The Jar”

If you gain weight (more than 2 pounds) or do not complete post-holiday weigh-in session, then you forfeit your entry fee
If you maintain, you get your entry fee back and win more! Participants who “maintain” split the forfeited entry fees

Who can participate?
All members of the Crouse family are invited to participate (18 and older). If you are signing up a family member, the employee must coordinate sign-up and payment for family members (ex: spouse).

Weigh-in Deadlines:
Must have pre-holiday weight recorded between Nov. 11 – Nov. 22
Must have post-holiday weight recorded between Jan. 2 – Jan. 10

Weigh-in Methods (visit www.crouse.org/maintain for details):
Method #1: Use a Higi machine at various local pharmacies (i.e. Rite Aid or Wegman’s)
Method #2: Weigh-in with Ngoc Pham at Crouse Hospital on 8 Memorial

Question Title

* 1. Please enter your information.

First Name

Last Name

Badge # (Crouse/CMP Employees)

Email address

Phone number

Question Title

* 2. Organization:

Crouse Hospital Employee

CMP Employee

PCON Student

Other (please specify)

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* 3. Family members are welcome to participate.
The employee will be required to coordinate payment and deliver winnings to the additional participants.
Please indicate if you are signing up any family member(s) and indicate participant name(s):

No, I am not signing up any family members

Yes, I would like to sign up the following participants (indicate name and relationship to you):

Question Title

* 4. Weigh-in Method:
Must use same method for pre and post holiday weigh-in session

Higi Station (available at Rite Aid and Wegman's pharmacies, visit www.crouse.org/maintain for instructions)

Onsite with Ngoc Pham on 8 Memorial (visit www.crouse.org/maintain for schedule of weigh-in sessions)

Question Title

* 5. Form of Payment (payment due Nov. 21 - no exceptions)
Cash/Check can be delivered to Crouse Hospital Human Resources Desk on 8 Memorial or to your organization's Holiday Challenge contact person. Please include the amount and names of participant(s) with the payment.

I will use this online form to submit Payroll Deduction Authorization (Crouse/CMP employees only)

Cash or Check (checks made payable to Crouse Hospital)

Question Title

* 1. Please enter your information.

Question Title

* 2. Organization:

Question Title

* 3. Family members are welcome to participate. The employee will be required to coordinate payment and deliver winnings to the additional participants. Please indicate if you are signing up any family member(s) and indicate participant name(s):

Question Title

* 4. Weigh-in Method:Must use same method for pre and post holiday weigh-in session

Question Title

* 5. Form of Payment (payment due Nov. 21 - no exceptions)Cash/Check can be delivered to Crouse Hospital Human Resources Desk on 8 Memorial or to your organization's Holiday Challenge contact person. Please include the amount and names of participant(s) with the payment.

* 3. Family members are welcome to participate.
The employee will be required to coordinate payment and deliver winnings to the additional participants.
Please indicate if you are signing up any family member(s) and indicate participant name(s):

* 4. Weigh-in Method:
Must use same method for pre and post holiday weigh-in session

* 5. Form of Payment (payment due Nov. 21 - no exceptions)
Cash/Check can be delivered to Crouse Hospital Human Resources Desk on 8 Memorial or to your organization's Holiday Challenge contact person. Please include the amount and names of participant(s) with the payment.