Wellness Champion
Application
Contact Information
Name
Employee ID Number
Work Location
Email Address
Work Phone
Manager/Supervisor Name
Wellness Experience
Do you have any current or prior experience in engaging others in wellness activities? If yes, please
explain.
___ No
___ Yes
Personality Traits
List three personality traits that you think best describe you.
1.
2.
3.
Why You Make a Good Candidate
The role of Wellness Champion is a highly valued and honorable position to hold. Why do you think you
should be selected to this position for 2016? Write as much or as little as you would like.
Agreement and Signature
The Wellness Champion position could require up to 2 hours each month of dedication. There is no
Wellness Champion charge code. Because of this, supervisor or manager approval is required before
applications can be submitted and reviewed by the Serco Wellness Team. Please have your manager or
supervisor fill out the following information:
I, ____________________________ (Supervisor/Manager Name), certify that the applicant named above
is fit to be a 2016 Wellness Champion. I approve this nomination.
Supervisor/Manager Signature:
Our Policy
It is the policy of this organization to provide equal opportunities without regard to race, color, religion,
national origin, gender, sexual preference, age, or disability.
Thank you for completing this application form and for your interest in becoming a Serco Wellness
Champion.
Please submit the completed application to Wellness@serco-na.com. Applicants will be informed via
email whether approved or denied once final decisions have been made.