Organized Wellness Activity

Athletic Event Form

VI_OWAAE_1113
2014 The Vitality Group
Instructons: Please complete the form below and submit it to Vitality with proof of your athletc event completon. This proof can include ONE
of the following:
An ocial copy of race results with your name highlighted or underlined
An ocial certcate of completon or
A copy of race bib
For charity events only: We will also accept a copy of your registraton conrmaton as proof of event partcipaton.
To qualify for Vitality Points, you must submit proof of your athletc event within 90 days of the event taking place. You are eligible to earn
points for one athletc event per day.

Secton A: Members Informaton
First Name of Member Who Completed the Actvity: Last Name of Member Who Completed the Actvity:
Vitality ID: Date of Birth:

Secton B: Athletc Event Informaton
Name of Event: Date(s) of Event:
Type of Athletc Event (5k, triathlon, road bike race, etc.): Event Distance:
I am including the following as proof of my athletc event completon (check one):
Secton C: Members Declaraton and Consent
By signing this form, I atest that I completed this athletc event as listed above and that the informaton submited with this
request is accurate and complete. I consent and agree that Vitality or any of its representatves has the right to verify and review
informaton to substantate informaton and representatons herein for the purpose of awarding Vitality Points.
Members Signature: Date of Signature:
An ocial copy of race results
with my name highlighted or
underlined
An ocial certcate of
completon
A copy of my race bib
Charity Events Only: A copy of
my registraton conrmaton
Questons? Please feel free to contact a Vitality Customer Care representatve at 877.224.7117 or wellness@powerofvitality.com.
Notce of Reasonable Alternatve Standard: If it is medically inadvisable or not plausible for you to engage in
physical actvity, you may complete and submit the Physical Actvity Accommodaton Waiver. Doing so will allow you to
earn Vitality Points in the Physical Actvity category for less strenuous or non-physical actvites. To access these forms,
please log into your Vitality account and navigate to Forms > Medical Accommodatons / Waivers.
We encourage you to submit this actvity online. Simply log into your Vitality account, navigate to Home > Submit Actvity, select your
actvity and follow the prompts to submit your informaton and supportng documentaton. Alternatvely, you may email your submission to
wellness@powerofvitality.com or fax it to 877.224.7110.
Please note, submission via email is not secure untl received by Vitality. For your protecton, Vitality strongly recommends the use of our
online submission opton.
Hassan Azhar
VS00797080
Hassan Azhar