* 1. Name:

* 2. On which campus are you located?

* 3. Email Address:

* 4. Campus Mailing Address:

* 5. Job Title:

* 6. Department:

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

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

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

* 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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