MUS Wellness Champion Application 2017/2018 -- New WellChamps

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* 1. Name:

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* 2. On which campus are you located?

Billings (MSU Billings)

Billings (Southern AES Research Center)

Billings (City College)

Bozeman (MSU)

Bozeman (Gallatin College)

Bozeman (MSU Extension)

Butte (Montana Tech)

Butte (Highlands College)

Conrad (Western Triangle AES Research Center)

Corvallis (Western AES Research Center)

Dillon (UM Western)

Flathead Lake Biological Station

Glendive (Dawson Community College)

Great Falls (Great Falls College)

Hamilton (Bitterroot College)

Havre (MSU Northern)

Havre (MSU Northern AES Research Center)

Helena (OCHE)

Helena (Helena College)

Helena (State Bar)

Helena (GSL)

Helena (Natural Heritage Program)

Kalispell (Flathead Valley Community College)

Kalispell (Northwestern AES Research Center)

Miles City (Miles Community College)

Miles City (Ft Keough AES Research Center)

Missoula (UM)

Missoula (Missoula College)

Moccasin (Central AES Research Center)

Sidney (Eastern AES Research Center)

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* 3. Email Address:

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* 4. Campus Mailing Address:

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* 5. Job Title:

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* 6. Department:

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* 7. Please describe briefly your philosophy of health & wellness.

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* 8. In your opinion, what is the biggest need on your campus regarding health and wellness?

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* 9. What personal qualities or characteristics will you contribute as a Wellness Champion?

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* 10. As an MUS Wellness Champion for 2017-2018, I will:
-Participate in MUS Wellness events, education, and programs when possible.
-Promote MUS Wellness events, programs, and initiatives on my campus; especially promoting to other coworkers in my department.
-Respect all confidentiality and privacy standards by not disclosing any personal information, health-related or otherwise, of anyone whom I encounter while volunteering as a Wellness Champion.
-Comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I will not create, receive, use nor disclose any protected health information (demographic, medical, or financial) through email or written communications and must safeguard all security measures.
-Be me!

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