Name of Event*
Take a look at the current LiveWell Fit event list to find an event in your area.

PLEASE NOTE THAT ONLY THOSE EVENTS LISTED ON THE TRUST WEBSITE ARE ELIGIBLE FOR REIMBURSEMENT

Event Location*

Event Date*

Event Distance*

Complete this section with the employee's information:

Employee Name*

Last Four Digits Of Employee Social Security Number (xxxx)*

Employee Address*

City*

State*

Zip Code*

Employee Date of Birth*

Who is participating in the event? Complete all fields for each participating family member.

Participant First Name*

Participant Last Name*

Relationship to Employee? * (select one)
EmployeeSpouseDependent

Participant Phone Number

Participant Email Address*

Participant T-Shirt Size

+ Add New Participant