SEUSA Enrollment and Liability Form 2019 Question Title * 1. 2019 Participation Agreement/ReleaseFYI... EVERY TIME YOU CLICK ON THE LINK TO THIS AGREEMENT, THE SYSTEM THINKS YOU ARE A NEW PERSON SIGNING UP. IF YOU HAVE ALREADY FILLED THIS OUT AND GOT A THANK YOU PAGE, THERE IS NO NEED TO FILL THIS OUT AGAIN. You will get an e-mail confirmation within 15 minutes of completing this form. Please enter your e-mail carefully and correctly! Below I designate my decision to participate in the Sumitomo Electric USA, Inc. Wellness Program. If my designation is YES, I agree to give One Stop Wellness LLC. permission to access/receive downloads from third party vendors for Blood Work data, Health Assessment data, Survey Information, and other data ONLY pertaining to the Sumitomo Electric USA, Inc. Wellness Program. This information will not be shared with your employer or the associated employer, except in an aggregate format that abides by HIPAA Guidelines Please mark your designation (Yes or No) below. YES I DO want to participate in the Sumitomo Electric USA, Inc. Wellness Program. NO I DO NOT want to participate in the Sumitomo Electric USA, Inc. Wellness Program. Question Title * 2. First Name Question Title * 3. Middle Name Question Title * 4. Last Name Question Title * 5. Date of Birth Date of Birth Date Question Title * 6. Male or Female Male Female Question Title * 7. Contact Information (This information will not be used for any form of solicitation) Address: * City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: * Phone Number: Question Title * 8. Electronic Signature:I understand that by clicking "I Confirm" below I am stating that the information belongs to me and is correct. I also understand that this IS MY ELECTRONIC SIGNATURE that will designate my choice on the Agreement/Release Form (above). I Confirm/ My Signature.....(This is my Electronic Signature) I DO NOT Confirm/ I am NOT giving my signature.....(I am choosing to NOT give my signature either because the information provided above DOES NOT belong to me or because I'm choosing to void my right to participate in the "Wired Up" Harnessing Better Health and Wellness Program. Next