SEWS Enrollment and Liability Form 2027 Survey

1.Participation Agreement/Release

Below I designate my decision to participate in the Sumitomo Electric Wiring Systems 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 Wiring Systems 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.(Required.)

YES I DO want to participate in the Sumitomo Electric Wiring Systems Inc. Wellness Program.

NO I DO NOT want to participate in the Sumitomo Electric Wiring Systems Inc. Wellness Program.

2.First Name(Required.)

3.Middle Name

4.Last Name(Required.)

5.E-mail
IMPORTANT - Enter carefully, completely and correctly as this is the address used to send your confirmation. Your confirmation will take no longer than 15 minutes, but in most cases is immediate.

6.ID Number(Required.)

ID Number (Associate Identification Number)

7.Date of Birth(Required.)

Date of Birth

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

8.Male or Female(Required.)

Male

Female

10.Contact Information (This information will not be used for any form of solicitation)(Required.)

Address:

City/Town:

State:

ZIP:

Phone Number:

11.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).(Required.)

I Confirm/ My Signature.....(This is my Electronic Signature)