Working On Wellness

WOW Enrollment Form

The MPCC “WOW” Concept ...

The concept of the Mid-Plains Community College “WOW, Working on Wellness” program is to provide opportunities for employees to develop and maintain balanced and healthy lifestyles. In addition, “WOW, Working on Wellness” will help create an environment within the institution that cultivates positive communication and healthy relationships, and in turn, will serve as a model for cultural and educational enrichment within the various communities of the MPCC area.

YES! Sign me up for the MPCC WOW! Working on Wellness Program.
Please fill out and/or sign top and bottom sections
 


Name (please print)
   

Department Location (NPCC, MCC, BB, IMP, OG, VAL)
   

Phone Email

Please circle T-Shirt Size: SM   MED   LG   XL   XXL

RELEASE OF LIABILITY

In consideration of my participation in the Mid-Plains Community College (MPCC) Working on Wellness (“WOW”) program, I hereby release MPCC, its officers, agents, employees and Board of Governors, and any other persons associated with the WOW program, from any and all liability for damages of any kind, which might occur while I am participating in WOW. I am aware of the risks of participating, and I understand and agree that my participation is strictly voluntary, and I freely choose to participate. I understand that MPCC provides no specific medical coverage for participation in this program, and that I would be responsible for any costs I incur as a result of participation in the WOW program.
 


Print Name
 

Date
 

Signature

Send completed form to:

Wendy Schramm
Mid-Plains Community College
Business Office
1101 Halligan Drive
North Platte, NE 69101

Rev 8/8/07

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Working on Wellness Last Update: 01/25/2008
Send Inquiries to: Wellness Team