Registration Form

Name__________________________________

Title____________________________________

Company_______________________________

Address________________________________

City________________State_____Zip_______

Telephone__________________________


email ________________________________

(optional)
Number of employees _______

Do you have a company wellness program?
Yes ______ No ______

Please indicate the committee(s) in which you would be interested:

_____ Program

_____ Membership

_____ Communication

_____ Special programs


Yearly fees for membership are $160.

Please make check payable and mail to:
The Wellness Council of Northeast Ohio
433 South State Street
Painesville, Ohio 44077
(440) 354-8057; hsense@en.com

For further information call:
Steve Musgrave at (440) 354-8057