Online Application

PEIA Pathways To Wellness Online Application For Worksite Participation

Please submit application online or by mail to:
PEIA Pathways to Wellness Support Letter
109 Capitol Street
Charleston, WV 25301
Have your letter of support completed by your administrator before you initially meet with a Health Promotion Consultant. Click here for a sample.
Answer the following questions and then hit the 'submit' button at the bottom of the page. 
*Required Fields

Agency Name*  

Address, City, State, Zip Code*  

County:*     

Phone #:*     Fax #:   

Number of Employees:*     

Number of Buildings/Locations:*     

Administrator's Name and Title:*   

Administrator's Phone:*    

Administrator's E-mail Address:*    

Worksite Coordinator's Name (if applicable) and Title:

Worksite Coordinator's Phone:   

Other Contact Phone/Emergency Phone:   

Worksite Coordinator's E-mail Address:   

  I agree to allow my e-mail address(es) to be placed on the PEIA Pathways to Wellness website.

Our worksite can provide the following in-kind services (check all that apply):
  Copying
  Fax
  Postage/Mailing
  E-mail
  Computer
  TV/VCR
  Conference Room/Program Space
  Overhead Projector
  Other (please specify):

How did you hear about the program?

STATEMENT OF PARTICIPATION: I have read the enclosed information regarding the PEIA Pathways to Wellness program and understand the commitment for worksite participation and the responsibilities associated with the volunteer worksite coordinator, which includes allowing attendance at the annual Worksite Coordinator Training and conducting a health screen.  (By checking the box below you are authorizing your signature) 
Signature Box Name of Signee:*  
Today's Date:*   

Thank you for your interest in the PEIA Pathways to Wellness program. Hit the submit button to send this application.

Office Use Only: ID Number:
Date Sent to HPC: