Sign up to be a PEBB Wellness Coordinator

Sign up to be a PEBB Wellness Coordinator

Are you interested in leading or encouraging wellness efforts in a state agency or university where PEBB benefits are offered? Complete and submit the form below. No experience required!
As a PEBB Wellness Coordinator, you'll receive information about PEBB wellness tools, resources, and grant opportunities. We will also invite you to Wellness Coordinator meetings, webinars, live wellness events, and more.

Your participation and feedback will help PEBB provide the resources you need. We appreciate your passion and look forward to helping you succeed!
Full Name*

First NameLast Name
Title
Agency/University (building or, department where you plan to promote wellness activities)*
(Example: ODOT Region 12, OSU Bend, ODHS West Eugene Family Center, etc.)
Shipping Address (Where UPS can deliver posters/packages. No PO Boxes, please.)*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*
10 digits including area code with dashes
What type of phone is the number above?*

Land Line (work)Land Line (personal)Cell phone (work or personal)
Type a question

Type option 1Type option 2Type option 3Type option 4
Does this phone number require an extension? If so, enter it here.*

No extension needed.Other
E-mail #1 (where you want to receive PEBB Wellness Coordinator info)*
E-mail #2 (optional - if you have a second address where you also want to receive PEBB Wellness Coordinator info)
example@example.com
How did you hear about the opportunity to become an PEBB Wellness Coordinator?*
If "Other", please describe:
Why are you interested in being an PEBB Wellness Coordinator?
If you could lead your workplace to achieve one Wellness Goal within the next 12 months, what would it be?
What could PEBB do to help you achieve the Wellness Goal you provided above?

Do you know others who might be interested in being an PEBB Wellness Coordinator? Let us know and we'll send them an invitation.

	Full Name	Email Address	Phone Number	Employer/Entity
1
2

Thank you for helping promote wellness in the workplace!
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