* 1. Name:

* 2. On which campus are you located?

* 3. Email address:

* 4. Campus mailing address:

* 5. Job Title:

* 6. Department:

* 7. 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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