2008 Medica Worksite Health Assessment Campaign
Registration Form

Sign Up Today!

Complete the registration form to participate in the 2008 Health Assessment Campaign. Training, materials and incentives will be provided to your company. To participate, your company will need to designate a month to participate, provide a site coordinator, and attend a site coordinator training session. If you have any questions, please contact your Account Manager.

Program Criteria

Complete the information for each of the following criteria below:

*Designated Worksite Health Assessment Coordinator

*Name of Coordinator

Coordinator Contact Information (if different from above)

Address:

City:
State:
Zip:
Email Address:
Telephone:

*Month your company will implement at Worksite Health Promotion Campaign

(Remember to allow 4-6 weeks prior to your implementation month to receive training and materials).

Registration Information

1. The Site Coordinator will attend one of the following Worksite Health Assessment Training Sessions:

Group Training Session (at Medica in Minnetonka) :

Thursday, September 11 from 9—10:30 a.m. (Implement in October or November)

WebEx Training :

	Thursday, July 17 from 10:00—11:00 a.m.
	Tuesday, August 5 from 10:00—11:00 a.m.
	Wednesday, September 10 from 10:00—11:00 a.m.

Account Manager Training:

	I would like to talk to my Medica Account Manager to discuss other possible training options.
	I already have coordinated training through my Medica Account Manager.

2. Medica would like to thank each company for implementing the Worksite Health Assessment Campaign by providing the site coordinator with a complimentary sporty tote bag. (one per company). Would your company site coordinator like to receive this complimentary bag?

	Yes
	No thank you

3. How did you find out about this program?