Wellness Program Consent Form
Participant Information
Full Name
Date of Birth
Contact Number
Email Address
Emergency Contact
Name
Contact Number
Relationship
Medical Information
Relevant Medical Conditions or Allergies
Consent and Acknowledgement
I confirm that I have read and understood the information about the Wellness Program.
I understand the potential risks and benefits and consent to participate in the program.
I acknowledge that I can withdraw from the program at any time.
Participant Signature
Date
Witness Signature
Date