SEWS Spouse Registration/Participation Agreement 2024

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* 1. Participation Agreement/Release

Below I designate my decision to participate in the Sumitomo Electric Wiring Systems Wellness Program. If my designation is YES, I agree to give One Stop Wellness permission to access/receive downloads from third party vendors for Blood Work data and other data ONLY pertaining to the Sumitomo Electric Wiring Systems Wellness Program. This information can only be shared with your spouse's employer 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 Wellness Program.

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

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* 2. Last Name

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* 3. First Name

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* 4. Middle Name

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* 5. Date of Birth

Date of Birth

Date

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* 6. Male or Female

Male

Female

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* 7. Your Spouse's Sumitomo Work Location

Bowling Green KY Corporate

Lexington KY

Edmonton KY

Scottsville KY

Franklin KY

La Vergne TN

Jeffersonville IN

Canton MS

Moody AL

Farmington Hills MI

Marysville OH

San Antonio TX

El Paso TX (Customer Service Center) ECSC

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* 8. Contact Information (IMPORTANT: This is the contact information used to deliver your results).

Address: *

City/Town: *

State: *

ZIP: *

Phone Number:

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* 9. Email - This is the email address used to send your confirmation. Please enter this carefully, completely and correctly.

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* 10. 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.

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* 2. Last Name

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* 3. First Name

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* 4. Middle Name

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* 5. Date of Birth

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* 6. Male or Female

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* 7. Your Spouse's Sumitomo Work Location

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* 8. Contact Information (IMPORTANT: This is the contact information used to deliver your results).

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* 9. Email - This is the email address used to send your confirmation. Please enter this carefully, completely and correctly.

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* 10. 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).

* 10. 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).