Please fill out the form to submit your Wellness Pays activities
W Number (include the W):
First name: Last name
Date of Activity (mm/dd/yyyy) Type of Activity Choose one: Preventative Screening Physical Activity Healthy Behavior Activity Description of activity (if needed - race name, etc)
Type of Activity Choose one: Preventative Screening Physical Activity Healthy Behavior
Activity
Description of activity (if needed - race name, etc)
