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Wellness Incentive Form

Rewarding Your Commitment to Health

Submit the Wellness Incentive Form to claim rewards for your participation in wellness programs. Take steps toward a healthier lifestyle while earning valuable incentives.

 

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Incentive Details
Incentive Payment:
  • Employees & Retirees will receive $200; Employee Spouses & Retiree Spouses will receive $100.
  • The incentive is paid via direct deposit.
  • Employees, spouses, retiree and retiree spouses covered by the City health insurance plan are eligible.
Form Deadline:
  • Submit requirements by April 18th, 2025 and receive incentive: May 2nd, 2025
  • Submit requirements by May 3th, 2025 and receive incentive: June 13th, 2025
  • Submit requirements by June 27th, 2025 and receive incentive: July 11th, 2025
  • Submit requirements by September 5th, 2025 and receive incentive: September 19th, 2025
  • Submit requirements by October 3rd, 2025 and receive incentive: October 17th, 2025
  • Submit requirements by November 7th, 2025 and receive incentive: November 26th, 2025
Directions:
  • Employees and Employee Spouses must complete enough tasks to have at least 175 points.
  • Some task require documentation to be submitted. Please look for the (*) by the task
  • If documentation is required but not submitted, the individual will not receive credit for that task.
  • WellRight Platform – Each category below will have an activity/challenge for each month.
    Items will be posted quarterly on the platform:

    • Fitness/Movement
    • Mental Health
    • Nutrition

**There will be more task to participate in through WellRight, in addition to the ones stated below.
Take a look!

**There will be more task to participate in through WellRight, in addition to the ones stated below.
Take a look!

Wellness Platform (WellRight) – Active Employees

If you complete the wellness incentive through WellRight, you do not need to complete the paper form. The Human Resources department will receive a report with everyone that completes the points through the portal.

Incentive Requirement:
  • Complete desired tasks below to earn points
  • Must have 150 points to earn wellness incentive

City of Racine Wellness Incentive Form

Check Your Status(Required)
MM slash DD slash YYYY
List
Task
Points
Completed (put an “X”)
 
Tasks that require documentation:

Consultation with a Licensed Health Professional

100

Smoking cessation program (completion of entire program) *Must submit program completion documentation

70

MM slash DD slash YYYY

Blood Pressure monitoring – 3 check-ins required

50

Cholesterol monitoring – 3 check-ins required

50

Bone Density Screening

Preventative cancer screening

*Must provide appointment confirmation for all appointments that list dates and times of each appointment – Do not just write dates and time(s) of appointments next to task above

Give Back; Volunteer at an Event (Minimum 1 hour of volunteer time

50

*Must submit City of Racine Financial Wellness Consultation Form

Attend a Financial Wellness consultation through the Racine Financial Empowerment Center * Must submit City of Racine Financial Wellness Consultation Form

20

Must submit items for each activity through the Wellness Platform to receive the points for each challenge

Total number of points:

Quarter 1:
Quarter 2:
Quarter 3
Quarter 4

Participate in an organized athletic event (walk, run, triathlon, etc)

10 points per event; maximum of 50 points

Meet with a personal trainer (Maximum of 1 session)

10

Task that do not require documentation:

MM slash DD slash YYYY
Blood pressure, height, weight, body fat %, BMI, tobacco attestation and a fasting blood draw (lipid panel and blood glucose)

50

50

MM slash DD slash YYYY

Preventative Vision Exam *Must provide appointment confirmation or provide the name of vision office and date of visit

MM slash DD slash YYYY
MM slash DD slash YYYY

15 points per visit; maximum of 30 points

MM slash DD slash YYYY

Preventative Vision Exam Name of Vision Office:

Attend Aurora EAP Webinar done quarterly through Zoom

15

MM slash DD slash YYYY

15 points per vaccine; maximum of 30 points

Watch online webinar, here: (maximum of 2 videos)

Click Here

Clear Signature
MM slash DD slash YYYY
Clear Signature
MM slash DD slash YYYY

Submit this completed form, NO LATER THAN November 7th, 2025 to

City Hall, Human Resources, Room 204, 730 Washington Avenue, Racine, WI, 53403

Download Wellness Incentive Form
About City of Racine Human Resources

Welcome to the City of Racine’s Human Resources Department. Our dedicated team is committed to empowering employees, fostering a positive and productive workplace, and recruiting top talent to serve our community. Learn more about our values, goals, and the services we provide to support the city’s continued growth and success.

Read More Contact Us
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