Utilities Fitness Center

Utilities Fitness Center

4412 66th Street W., Bradenton, FL 34210
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 NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Phone Type*

CellHomeWork
Email*
example@example.com
Employee Status*

EmployeeSpouseDependent (19+)
Department/Location*
Employee ID#*
Do you have an access card for your agency/department?*

YesNo
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?*

YesNo
Aetna ID (W#)*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone 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 yearI acknowledge that as a MYC Health Plan member, I receive 5 FREE sessions with an RD, LAMP, or Health Coach 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:

Utilities Fitness Center

Acknowledgements: