SEDU/ICS Enrollment and Liability Form 2019

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* 1. 2019 Participation Agreement/Release

FYI... 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.

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* 2. First Name

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* 3. Middle Name

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* 4. Last 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. Contact Information (This information will not be used for any form of solicitation)

Address: *

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number:

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* 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.

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* 2. First Name

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* 3. Middle Name

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* 4. Last Name

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* 5. Date of Birth

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* 6. Male or Female

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

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* 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).

* 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).