Utilities Fitness Center

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.

NOTE: The Utilities Fitness Center is open to BCC employees and their adult covered dependents only.

For best results please use Chrome, Firefox, or Edge when completing this form.

Name *

First Name Last Name

Date of Birth *

Date

Phone Number *

Phone Type *

Cell Home Work

Email *

example@example.com

Employee Status *

Employee Spouse Dependent (19+)

Department/Location *

Employee ID# *

Do you have an access card for your agency/department? *

Yes No

Access Card # *

Only spouses/dependents of BCC employees who are age 19+ and covered on the YourChoice Health Plan are able to utilize this facility.

Are you a YourChoice Health Plan Member? *

Yes No

Aetna ID (W#) *

Emergency Contact *

First Name Last Name

Emergency Contact Phone Number *

Area Code Phone Number

Emergency Contact Relationship (friend, spouse, etc.) *

Acknowledgements:

Liability Waiver Terms & Conditions

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.
The Fitness Center hours are M-F 5am-9pm & Sat/Sun 7am-7pm, and that during the busiest times of 10am-1pm and 3pm-5pm, equipment availability may be limited.
I am required to park in the shell parking lot, south of the fitness center building, during business hours ( 7a-4p).

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 sessions of Personal Training at no cost per calendar year I acknowledge that as a MYC Health Plan member, I receive 5 FREE sessions with an RD, LAMP, or Health Coach per calendar year I acknowledge that as a MYC Health Plan member I have access to Hinge Health at no cost as a resource to address muscle/joint discomfort I acknowledge that as a MYC Health Plan member that I understand there is a Health Improvement Incentive Program (HiiP) available to Employees on the Health Plan to improve overall health and earn additional money each year I 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 aches I understand there are masks available upon request While 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