Health Champion Registration Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Email Address (please use AdventHealth email address) Question Title * 4. Employee OPID Question Title * 5. Which campus are you located? Altamonte Apopka Celebration Children's Courtland Daytona Deland East Orlando Fish Memorial Heart of Florida Kissimmee Lake Destiny/Progressive Bldg Lake Wales Maitland/Trickel New Smyrna Beach Orlando Palm Coast Waterman Winter Garden Winter Park Not located on one of the main campuses. Please list your physical work address. Question Title * 6. Are you part of Integrated Health Services (IHS)? No Yes; please list what group you are a part of (i.e. Centra Care/AHMG/AHU/Hospice/etc.): Question Title * 7. Job Title Question Title * 8. Manager's Full Name Question Title * 9. What interests you most about becoming a Health Champion? Question Title * 10. How did you hear about Health Champions? Fellow Health Champion Employee Health and Well-being Partner CREATION Life Experience Hospital Event Found it on the website Other (please specify) Question Title * 11. If you were referred by another Health Champion, please share their name. Question Title * 12. I have the approval of my direct supervisor to become a Health Champion. Yes No Done