Downtown MYC Wellness Center

Downtown MYC Wellness Center

1012B Manatee Ave W, Bradenton, FL 34205
A Liability Waiver must be on file in order to gain access to the fitness center and/or utilize group fitness, personal training, etc. For questions regarding this form, please contact the YourChoice Fitness Center at 941.748.4501 x3979.

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
I am requesting access for:*

Fitness Center OnlyFitness Center & LAMP Entrance
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Phone Type*

CellHomeWork
Email*
example@example.com
Employee Status*

EmployeeSpouseDependent (18+)RetireeFC Instructor/Trainer
Employee ID#:
Employee Badge# (first 5 numbers after the asterisk 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 Manatee
Which Agency are you retired from?
MSO Location*

CourthouseAll Others
Only spouses/dependents who are age 18+ and covered on the YourChoice Health Plan are able to utilize this facility.
Are you a YourChoice Health Plan Member?*

YesNo
Aetna ID (W#)
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 also understand this waiver will expire in one year and a new waiver must be submitted to continue access to the Downtown Fitness Center.
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 MYC 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 MYC Health Plan member
Acknowledgement of community risk and responsibility*

I will not enter the Fitness Center if I am experiencing any symptoms of SARS/Covid such as fever, headache, runny nose, cough, or body achesI understand there are masks available upon requestWhile the Fitness Center has taken numerous actions to mitigate risk, I acknowledge there is still inherent risk in participating in indoor group activities
Signature

Clear
Should be Empty:

Downtown MYC Wellness Center

Acknowledgements