SEWS Enrollment and Liability Form 2025 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. YOU WILL RECEIVE A CONFIRMATION E-MAIL TO THE ADDRESS YOU DESIGNATE BELOW. ENTER THIS INFORMATION CAREFULLY AND CORRECTLY.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. 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. Question Title * 2. First Name Question Title * 3. Middle Name Question Title * 4. Last Name Question Title * 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. Question Title * 6. ID Number ID Number (Associate Identification Number) Question Title * 7. Date of Birth Date of Birth Date Question Title * 8. Male or Female Male Female Question Title * 9. Work Site Location Bowling Green KY Corporate Lexington KY Jeffersonville IN (ICSC) Edmonton KY Scottsville KY Franklin KY Henderson KY La Vergne TN Canton MS Moody AL Farmington Hills MI Marysville OH San Antonio TX El Paso TX (Sumi-Texas Wire) EPM El Paso TX (Customer Service Center) ECSC Princeton IN Question Title * 10. 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: * Phone Number: Question Title * 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). 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