Fillable Wellness Activity Liability Acknowledgement Form INFORMED CONSENT AND (North Carolina)

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Wellness Activity Liability Acknowledgement Form INFORMED CONSENT AND (North Carolina)

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Wellness Activity Liability Acknowledgement Form
INFORMED CONSENT AND RELEASE FROM LIABILITY
EMPLOYEE/RETIREE NAME:
AGENCY:
I understand that my participation in the Miles for Wellness walking challenge is strictly
voluntary and is not a requirement of my employment with the State of North Carolina or any
State agency and, if applicable, is not a requirement of my State Government retirement. I am
aware that I should consult with a physician before I undertake any physical exercise program. I
will not, nor will anyone acting on my behalf, hold the State of North Carolina, or any of its
agencies, officers, agents, or employees, responsible for any injuries that might occur from my
participation in this wellness activity.
I acknowledge that I have read and understand this Wellness Activity Liability
Acknowledgement Form and that I am freely and voluntarily signing it.
EMPLOYEE/RETIREE SIGNATURE:
DATE:
Miles for Wellness is sponsored by the Total Rewards Division of the Office of State Human Resources.
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Wellness Activity Liability Acknowledgement Form INFORMED CONSENT AND (North Carolina)

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Completed 8 March 2021

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