Downtown MYC Wellness Center

Downtown MYC Wellness Center

1012 Manatee Ave W, Bradenton, FL 34205
A Liability Waiver must be on file in order to gain access to the LAMP entrance, main Wellness Center entrance and/or utilize group fitness, personal training, etc. For questions regarding this form, please contact Marcia Polese at 941.748.4501 x3969.

Please read the Liability Waiver Terms & Conditions prior to completing this form.

Please use Chrome, Firefox, or Edge for best reults when completing this form.
Is this your first time filling out a waiver or is this your annual update?*

First timeUpdate
Name*

First NameLast Name
Are you 18+?

YesNo (if your answer is no and you are 14-17, stop and fill out the minor waiver) NO ONE UNDER THE AGE OF 14 IS PERMITTED.
Phone Number*
Email*
example@example.com
Employee Status*

EmployeeSpouseDependent (18+)RetireeFC Instructor/Trainer
Employee ID#:
Employee Badge# (first 5 numbers after the plus sign on the back bottom of your employee ID card):
Employee Agency (If your Employee ID starts with M00 or M01, choose BCC)*

BCCCAOManatee ClerkDOHElectionsJUD12 FLCourtsGALHousing AuthorityMSOPort ManateePD12SAO12TCOPAOVote ManateeOther
Which Agency are you retired from?
MSO Location*

CourthouseAll Others
Only spouses/dependents who are age 18+ and covered on the YourChoice Medical Plan are able to utilize this facility. Ensure that your health insurance is in effect before filling out this waiver. An access card will not be created if coverage is not active.
Are you a YourChoice Health Plan Member?*

YesNo
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Relationship (friend, spouse, etc.)*
Acknowledgements

https://manateeyourchoice.com/wellbeingprograms/fitness/fitness-center-liability-waiver-terms.pdf

By signing this form, I acknowledge that I have read the Liability Waiver Terms & Conditions and understand this agreement, and I realize it relates to surrendering and releasing valuable legal rights and do so freely and voluntarily. I also understand that, when exercising at the Fitness Center, I am required to wear a Medical Alert Necklace after office hours when alone and no staff on duty.

I acknowledge this is a perk of my employment and misuse of this privilege will result in termination of fitness center access.

I also understand this waiver needs to be updated annually for access into the Wellness Center.

I acknowledge that this is private property of Manatee County Government and is under video surveillance.

I understand the use of the YourChoice Wellness Center is exclusively reserved for Manatee County Government Employees and adult members enrolled in the YourChoice Health Plan. Guests are not permitted at any time. Membership privileges will be revoked for the following violations:
- Bringing a guest to utilize the facility.
- Using another member's access card.
- Removing equipment from the facility.
- Intentional misuse or destruction of the equipment.
Please sign/type your full name to acknowledge:*
Please read and check all to acknowledge receipt of these benefits for those on the Manatee YourChoice Health Plan, or only check "I am not a MYC Health Plan Member"*

I acknowledge that as a Manatee YourChoice Health Plan member, I receive 5 FREE sessions with a Registered Dietician, LAMP Counselor, Health Coach, and Personal Trainer at no cost per calendar yearI am not a Manatee YourChoice Health Plan member
Acknowledgement of community risk and responsibility*

I understand there are masks available upon requestWhile the Wellness Center has taken numerous actions to mitigate risk, I acknowledge there is still inherent risk in participating in indoor group activities
Please sign/type your full name to acknowledge:*
Please Note: Access is not automatic with the submission of this waiver. Please allow up to 5 business days for access. A confirmation email will be sent once your access has been updated or your card has been created.

A $5.00 replacement fee is required for any lost cards. Must be paid to the cashier on the 3rd floor of the administration building.
Should be Empty: