Organization Registration 2018 Lifesaver Wellbeing Series Register online at: https://s.zoomerang.com/r/Org2018LifesaverReg Question Title * 1. YES! I pledge that our organization is committed to wellbeing and participating in the 2018 Lifesaver Wellbeing Series. As a Team Champion I will:* Submit and share "Lifesaver" success stories* Utilize the free monthly wellbeing resources such as downloadable materials, programs, lunch and learn presentations, wellness challenges and self-directed learning courses.* Keep my leadership team informed of the activities in which our organization is a part of as well as program results Yes Question Title * 2. Name of organization: Question Title * 3. Approximate number of Local & Regional Employees (Green Bay/De Pere, Northeast WI & Upper MI) Question Title * 4. Contact Information: Team Champion Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title * 5. As part of the registration process, Bellin Health requires health plan group number(s) for your organization. If unable to provide, please let us know who at your organization who can provide that information and a representative from the Bellin Health team will follow-up. Group #(s) for health plan: Name: Email Address: Phone Number: Question Title * 6. Please confirm: I have spoken with leadership at my organization and they support our commitment to the 2018 Lifesaver Wellbeing Series. Yes Leader's Name Question Title * 7. Please contact me with more information about how a Wellbeing Activator can help with our wellbeing program implementation. YES Comments: CONGRATULATIONS and THANK YOU for registering. Please visit www.bellin.org/lifesaver to start planning your organization's journey towards improved wellbeing. Nurse Jesse would like to assist you in planning your organization's wellbeing calendar so please contact her at: WellbeingConsultant@bellin.org or call: (920) 436-8668. Done