WorkingWell Corporate Wellness Interest Form

We strive to bring health and wellness to our communities by offering services that support your organization’s health and wellness initiatives. We would like to learn more about your company and your fitness needs. Please complete the survey below to receive more information on how we can help you!

Question Title

* 1. Your Name and Title

Your Name

Company

Company Address

Address 2

City/Town

State

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2. Type of Business

Advertising

City/State/Government

Education

Financial

Healthcare

Retail/Wholesale

Other (please specify)

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* 3. Number of Employees

5-10

11-25

26-50

51-74

75+

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* 4. As an employer would you be willing to subsidize a portion of your employee's membership?

Yes

N/A

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* 5. Please check the box if you would like more information on:

Fitness Services (health assessments, biometric screenings)

Physical Activity

Nutrition/Wellness Coaching

Mental Health & Stress Management

Chronic Diseases

Drug & Alcohol Testing Services

WorkSMART Occupational Health Services

Industrial Rehabilitation Services

Lunch N' Learns

Other (please specify)

WorkingWell Corporate Wellness Interest Form

Question Title

* 1. Your Name and Title

Question Title

* 2. Type of Business

Question Title

* 3. Number of Employees

Question Title

* 4. As an employer would you be willing to subsidize a portion of your employee's membership?

Question Title

* 5. Please check the box if you would like more information on:

Question Title

* 6. Please list any additional information you are interested in: