MYC Wellness Services Liability Waiver

MYC Wellness Services Liability Waiver
A liability waiver must be on file to utilize Health Coaching, Personal Training and Alignsmart services.
Date

MonthDayYear
Date
Are you 18+ on the YourChoice Medical Plan?*

YesNo
You must be a YourChoice Medical Plan Member and 18+ to utilize these services.
Name*

First NameLast Name
Email*
Phone Number*
I am*

EmployeeSpouseDependent (18+)Retiree
Employee Agency:*

Manatee County Government BOCCManatee County Clerk of CourtHousing AuthorityManatee Sheriff's OfficeTax CollectorMetropolitan Planning OrganizationProperty Appraiser OfficeSupervisor of ElectionsPort Authority/Seaport Manatee
Aetna ID#:*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Acknowledgements

Click Here to Read the MYC Program Liability Waiver.

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 acknowledge this is a perk of my health plan benefits and misuse of this privilege can result in loss of this benefit.

By participating in YourChoice Health Plan services (Health Coaching, Personal Training, and AlignSmart® Postural Assessment), members agree to provide at least 24 hours’ notice for appointment cancellations or rescheduling. Missed appointments or late cancellations will be considered No-Shows, and if applicable, one “Give Me Five” free session will be deducted with no replacement session provided.

This policy ensures fair compensation for contractors and equitable access to services for all members. Members also acknowledge they are not receiving the same services from another YourChoice contractor within the same month and agree to notify the appropriate parties if changing contractors.

If you are utilizing the personal training services with a YourChoice contractor, you understand that the five free personal training services cannot be utilized at a Crunch location.
Type your full name to acknowledge:*
Services available to YourChoice Health Plan Members (medical plan only):

Once your Health Plan benefits start, you have access to the following 5 FREE benefits:
1. Health Coaching
2. Personal Training (adult health plan members only)
3. Registered Dietitian Services
4. LAMP Services*
5. Symmetry Alignsmart
*LAMP Services are available regardless of health plan status. All other services are for health plan members only. Check our website for age eligibility for each service.
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