SEUHO Enrollment and Liability Form 2023 Question Title * 1. 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. If you would still like further confirmation e-mail onestopwellness@epbnet.com. Include your name and ID# and we will formally confirm that the system has captured your information. Also, if you would like a copy of what you have signed/designated we will be happy to provide that. Below I designate my decision to participate in the Sumitomo Electric USA Holdings, 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 Holdings, 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 Holdings, Inc. Wellness Program. NO I DO NOT want to participate in the Sumitomo Electric USA Holdings, 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. Email - This address is used to send your confirmation. Please be sure you have entered this correctly. 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