Wellness Program Agreement Template

WELLNESS PROGRAM AGREEMENT

Date: Date

Program Provider: Company/Organization Name

Address: Address Phone: Phone Email: Email Website: Website

Participant Information:

Name: Participant Full Name

Date of Birth: DOB Email: Email Phone: Phone Employee ID (if employer-sponsored): ID Employer: Employer Name

1. PROGRAM DESCRIPTION

Program Name: Wellness Program Name

Program Type: Comprehensive wellness/Weight management/Stress reduction/Fitness/Smoking cessation/Other

Program Duration: Start Date to End Date (Number weeks/months)

Program Components:

• Health risk assessment
• Biometric screening
• Personalized wellness plan
• Health coaching (individual/group)
• Fitness program
• Nutrition guidance
• Mental health/stress management
• Chronic disease management
• Smoking cessation
• Sleep improvement
• Preventive care coordination
• Online resources and tools
• Wellness challenges and incentives
• Other: Specify

Program Goals:

• Goal 1: e.g., Improve overall health and wellbeing
• Goal 2: e.g., Reduce health risks
• Goal 3: e.g., Promote healthy lifestyle behaviors
• Goal 4: e.g., Prevent chronic disease

2. PROGRAM SERVICES

Health Assessment:

• Comprehensive health risk questionnaire
• Identification of health risks
• Personalized risk report
• Confidential results

Biometric Screening (If Included):

• Blood pressure
• Cholesterol (total, HDL, LDL, triglycerides)
• Glucose/blood sugar
• Body Mass Index (BMI)
• Waist circumference
• Other measurements
• Performed by: Qualified healthcare professional

Health Coaching:

• One-on-one coaching sessions: Number sessions of Duration minutes
• Group coaching: Schedule
• Telephonic coaching: Frequency
• Email/message support
• Personalized action plans
• Goal setting and tracking
• Accountability and motivation

Educational Resources:

• Online portal access
• Educational materials and articles
• Webinars and workshops
• Mobile app (if available)
• Newsletter: Frequency
• Resource library

Wellness Challenges:

• Challenge 1: e.g., Step challenge
• Challenge 2: e.g., Healthy eating challenge
• Duration: Timeframe
• Prizes/incentives: Details

Support Services:

• Customer support: Email/Phone/Hours
• Technical assistance
• Other support

3. ELIGIBILITY AND ENROLLMENT

Eligibility:

• Open to all adults 18+
• Employer-sponsored: Employees of Company
• Insurance plan members
• Other: Requirements

Enrollment Process:

• Complete registration form
• Health risk assessment
• Biometric screening (if required)
• Establish baseline
• Set personal goals

Enrollment Period: Open enrollment dates if applicable

4. PARTICIPANT RESPONSIBILITIES

I Agree To:

• Provide accurate health information
• Participate actively and consistently
• Attend scheduled coaching sessions
• Complete assigned activities and tracking
• Follow personalized wellness plan
• Communicate with coach about progress and challenges
• Use program resources
• Practice healthy behaviors
• Re-assess at intervals to measure progress
• Provide feedback on program

Time Commitment:

Estimated X hours per week including:

• Coaching sessions
• Physical activity
• Meal preparation
• Tracking and logging
• Educational activities

5. FEES AND INCENTIVES

Program Cost:

• Free (employer-sponsored/insurance-provided)
• Participant pays: Amount
• Shared cost: Employer pays Amount, Participant pays Amount
• Subsidized based on participation

Payment (If Applicable):

• Payment due: Date/Schedule
• Payment method: Options
• Refund policy: Details

Incentives and Rewards:

Participants may earn incentives for:

• Completing health assessment: Incentive
• Completing biometric screening: Incentive
• Achieving participation milestones: Details
• Reaching health goals: Details
• Completing challenges: Prizes

Incentive Examples:

• Premium discounts (if insurance-related)
• Gift cards: Amount
• HSA/FSA contributions
• Wellness points redeemable for: Items
• Prizes and recognition

Incentive Terms:

• Requirements to earn incentives
• Distribution timeline
• Tax implications (if any)
• Reasonable alternative standards (if applicable)

6. HEALTH AND SAFETY

Not Medical Treatment:

This wellness program is educational and motivational. It is NOT a substitute for medical care.

I Understand:

• Program staff are not my healthcare providers (unless specified)
• Coaches provide guidance, not medical advice
• I should consult my physician before starting any new exercise or diet program
• I should continue seeing my regular healthcare providers
• I should follow my physician's advice
• Program does not diagnose or treat medical conditions

Medical Clearance:

I have/have not consulted my physician about participating.

I Will:

• Inform coach of any medical conditions or limitations
• Stop any activity that causes pain or discomfort
• Seek medical attention for any health concerns
• Inform program of any changes in health status

High-Risk Individuals:

If you have heart disease, diabetes, are pregnant, or have other serious health conditions, medical clearance is strongly recommended.

7. VOLUNTARY PARTICIPATION

I Acknowledge:

• Participation is completely voluntary
• I may withdraw at any time without penalty (subject to refund policy)
• I may decline any component of program
• Participation (or lack thereof) will not affect my employment (if employer-sponsored)
• Reasonable alternative standards available if I cannot meet health-related goals due to medical reasons

Reasonable Alternatives:

If it is unreasonably difficult or medically inadvisable for me to meet a health-related standard, I may contact Contact to request a reasonable alternative.

8. PRIVACY AND CONFIDENTIALITY

Privacy Notice:

See full Privacy Notice at: URL or provided separately.

Information Collected:

• Health risk assessment responses
• Biometric screening results
• Coaching notes and progress
• Activity and tracking data
• Participation records
• Incentive/reward information

How Information is Used:

• Provide personalized program
• Track your progress
• Communicate with you
• Evaluate program effectiveness (aggregated data)
• Research (de-identified data)
• If employer-sponsored: Report aggregate (not individual) results to employer

HIPAA and Confidentiality:

• Program complies with applicable privacy laws (HIPAA, ADA, GINA)
• Individual health information kept confidential
• Not shared with employer (if employer-sponsored) unless required by law or with your authorization
• Employer may receive aggregate reports on participation and outcomes

Your Individual Results:

• Shared with my primary care physician (with consent)
• Remain confidential to program staff
• Available to me via online portal

I Authorize:

• Sharing my results with my physician: Physician name
• Releasing aggregate (not individual) data to employer
• Participation in program research (de-identified data)

9. ASSUMPTION OF RISK AND LIABILITY WAIVER

Risks of Participation:

I understand that participation in wellness activities including exercise, dietary changes, and stress reduction techniques involves some risk including:

• Muscle soreness or injury
• Cardiovascular events (rare)
• Aggravation of existing conditions
• Other injuries or health events

I Voluntarily Assume These Risks.

Release of Liability:

To the extent permitted by law, I release Program Provider and its employees, agents, and contractors from liability for injuries, damages, or losses resulting from my participation, unless caused by gross negligence or intentional misconduct.

Employer Liability (If Employer-Sponsored):

Employer Name is not liable for any injuries or health issues resulting from program participation.

10. NO GUARANTEE OF RESULTS

I Understand:

• Results vary based on individual effort, adherence, genetics, and other factors
• No guarantee of specific weight loss, health improvement, or other outcomes
• Success depends primarily on my own actions and choices
• Program provides tools and support but cannot control my behavior

11. INTELLECTUAL PROPERTY

Program Materials:

All program materials including videos, worksheets, apps, and content are proprietary.

I Agree:

• Not to reproduce or distribute program materials
• Use materials for personal use only
• Not to share login credentials
• Respect copyright

12. COMMUNICATION

I Agree to Receive:

• Program-related emails and messages
• Coaching outreach
• Reminders and notifications
• Educational content
• Surveys and feedback requests

Communication Methods:

• Email: Email on file
• Phone/text: Phone on file
• Mobile app notifications
• Postal mail: Address on file

Opt-Out:

I may opt out of non-essential communications at any time.

Response Time:

Program staff will respond to inquiries within X business days.

13. DATA SECURITY

Security Measures:

• Encrypted data transmission
• Secure servers
• Access controls
• Regular security audits

Despite Precautions:

No data transmission is 100% secure. I assume risk of data breach.

In Event of Breach:

I will be notified per applicable laws.

14. TECHNOLOGY REQUIREMENTS

To Participate Fully:

• Internet access
• Email address
• Smartphone or computer for portal/app access
• Wearable fitness tracker (optional/provided)

Technical Support:

Available at: Email/Phone Hours: Hours

15. PROGRAM CHANGES AND TERMINATION

Program May Be Modified:

• Services, features, or incentives may change
• Advance notice provided when possible
• Substantial changes: Option to withdraw

Program May Be Terminated:

• By provider with notice
• Due to lack of funding (if applicable)
• Force majeure

If Program Terminated:

• Prorated refund (if applicable)
• Access to materials for X days
• Data exported or deleted per preference

I May Withdraw:

At any time by notifying Contact. Refund per refund policy.

16. CODE OF CONDUCT

I Agree:

• Treat staff and other participants with respect
• Provide honest information
• Not harass, bully, or discriminate
• Not share others' personal information
• Use program resources appropriately

Violations May Result In:

• Warning
• Suspension
• Termination from program without refund

17. DISPUTE RESOLUTION

Disputes:

Governed by laws of State.

Process:

1. Contact program administrator to resolve 2. Mediation (if agreed) 3. Arbitration/Litigation in Jurisdiction

18. ENTIRE AGREEMENT

This agreement constitutes the complete understanding between participant and provider.

Modifications:

Program may modify terms with notice. Continued participation indicates acceptance.

19. ACKNOWLEDGMENTS

I Acknowledge and Agree:

• I have read and understand this agreement
• I have had opportunity to ask questions
• I am voluntarily participating
• I understand this is not medical treatment
• I will consult my physician as appropriate
• I assume risks of participation
• I authorize collection and use of my health information as described
• I understand privacy protections
• I am eligible to participate
• Information provided is accurate

PARTICIPANT SIGNATURE:

Signature: _______________________

Printed Name: Participant Name

Date: _______________________

PROGRAM ADMINISTRATOR (Optional):

Signature: _______________________

Printed Name: Name

Title: Title

Date: _______________________

EMPLOYER REPRESENTATIVE (If Employer-Sponsored):

Signature: _______________________

Printed Name: Name

Title: Title

Company: Company Name

Date: _______________________