Live Well Waco Worksite Wellness Recognition Program

Organization Information

Question Title

* 1. Organization Profile

Organization Name

Name of Organization Contact

Department

Organization Address

City

State

Zip Code

County

Email Address

Phone Number

Question Title

* 2. Organization Information

Website Address

# of Years Wellness Program in Place

Total # of Employees

Mission Statement of Wellness Program

Budget For Wellness Program

Question Title

* 3. Certification:

As the employee representative for my organization, I certify that my organization implements the following health and wellness programs and these programs are currently in place and have been implemented within the previous calendar year.

Please type your full name in the text box below to state your understanding and agreement of the certification statement listed above.

Name

Title in Organization