Wellness Committee Request Form

Please use this form to request Wellness Committee funding for your office. The Committee has funding available for items in break rooms or offices that relate to wellness. Examples include break room furniture, appliances, support for city groups/organizations, or other related items.

All requests must be available for use to all City employees.

Requesting Department Name

What department is requesting the expenditure?

Requesting Contact Person

Who should the Wellness Committee follow up with?

Who will be responsible for the maintenance of any items purchased?

Location of request

Where will your item be installed?

Description of Expenditure

How will the request benefit the wellness of City employees?

Cost Estimate

How did you develop your cost estimate?

Will your requested item be open to all city employees?

YesNo

Will your requested item be open to the public?

YesNo