Complete Your Fitness Center Access Registration

Employee ID Number

Full Legal Name (as per official records)

Department/Division

Please specify your department:

Job Title/Role

Work Email Address

Work Phone/Extension

Employment Status

Contract End Date:

Contract End Date:

Original Hire Date

Primary Emergency Contact Full Name

Primary Emergency Contact Relationship

Primary Emergency Contact Phone Number

Primary Emergency Contact Email Address

Secondary Emergency Contact Full Name

Secondary Emergency Contact Phone Number

Do you consent to sharing your basic fitness program participation data (attendance, general activity type) with your organization's HR department for wellness program analytics?

I understand this data will be used in aggregate form and will not include specific health details or performance metrics.

I acknowledge that the emergency contact information provided is accurate and that these individuals have consented to be listed as my emergency contacts.

Has a healthcare provider ever stated that you have a heart condition or high blood pressure requiring medical supervision for exercise?

Please describe the condition and any exercise restrictions advised by your healthcare provider:

Do you experience chest pain, chest pressure, or unexplained shortness of breath during physical activity or at rest?

Please describe the frequency, severity, and triggers of these symptoms:

Have you ever experienced dizziness, fainting, or loss of consciousness during or after exercise?

When did this last occur?

Do you have any diagnosed metabolic conditions such as diabetes, thyroid disorders, or other hormonal imbalances that may affect exercise?

Please specify the condition and how it is currently managed:

Are you currently pregnant, have given birth within the last 6 months, or planning to become pregnant?

Please provide details and any specific exercise guidelines from your healthcare provider:

Have you had any surgeries, major injuries, or chronic musculoskeletal conditions (e.g., back, knee, shoulder problems) in the past 2 years?

Please describe the injury/condition, treatment received, and any ongoing limitations or rehabilitation requirements:

Select any current symptoms or health concerns that apply to you:

Are you currently taking any prescription medications or over-the-counter supplements that could affect your ability to exercise safely?

Please list all relevant medications/supplements and their purposes:

Have you been advised by a healthcare professional to obtain medical clearance before starting or continuing an exercise program?

Please upload your signed medical clearance letter from your healthcare provider:

How would you describe your current physical activity level?

Rate your current overall health status (1 = Poor, 5 = Excellent)

What are your primary fitness and wellness goals? (Select all that apply)

Do you require any special accommodations or adaptive equipment to participate in fitness activities due to a disability or physical limitation?

Please describe the accommodations or equipment needed:

Additional health information, concerns, or questions you would like to discuss with our wellness staff:

I acknowledge that participation in physical exercise and fitness activities involves inherent risks, including but not limited to musculoskeletal injury, cardiovascular events, and in rare cases, serious injury or death. I voluntarily assume all risks associated with using the fitness facilities and participating in wellness programs.

I hereby release, waive, discharge, and covenant not to sue the organization, its owners, directors, officers, employees, agents, and affiliates from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury that may be sustained by me while using the fitness facilities, regardless of whether such loss is caused by the negligence of the organization or its representatives.

I agree to abide by all facility rules, policies, and codes of conduct, including proper attire (closed-toe athletic shoes, appropriate fitness clothing), equipment usage guidelines, time limits on cardio equipment during peak hours, and respectful behavior toward staff and other members.

I understand that proper hygiene is required, including wiping down equipment after use, using designated towel services, and refraining from using facilities when ill or with open wounds.

I acknowledge that the organization reserves the right to revoke my fitness center access at any time for violations of facility rules, inappropriate behavior, or safety concerns, without refund of any fees paid.

Do you consent to the use of facility security cameras and potentially being photographed or video recorded for promotional materials, newsletters, or internal communications?

I understand I may withdraw this consent in writing at any time.

Please specify any privacy concerns or restrictions:

I have read and understand the guest policy, which allows registered guests only with prior authorization and under my direct supervision. I accept full responsibility for my guests' conduct and safety.

I agree to immediately report any equipment malfunctions, safety hazards, injuries, or medical incidents to facility staff and understand that failure to do so may result in suspension of access privileges.

Please acknowledge your understanding that this waiver is binding for the duration of your employment and fitness center access, and that you have had the opportunity to seek legal counsel if desired:

Type of Access Request

Please explain the circumstances requiring replacement and confirm you understand replacement fees may apply:

Previous access expiration date:

Please describe the requested changes and business justification:

Requested Access Level

Specify restricted areas and business justification for access:

Do you require 24/7 facility access outside standard operating hours?

Please provide detailed justification for 24/7 access (e.g., shift work, travel schedule, specific wellness program):

Do you wish to rent a personal locker?

Preferred Locker Size:

Locker Location Preference (if applicable)

Select any additional equipment or services you wish to request:

Have you previously lost a keycard or had one stolen?

Please provide details of the incident and confirm you understand security protocols for reporting future losses:

I understand that my electronic keycard remains the property of the organization, must be returned upon employment termination or upon request, and that I am responsible for all access granted via this credential.

I acknowledge that locker rentals are subject to availability, require separate fee payment where applicable, and that all personal items must be removed at the end of the rental period. Abandoned items will be disposed of after 30 days.

HR Eligibility Verification Checklist

HR Benefits Administrator Approval: Does this employee meet all eligibility criteria for fitness center access according to organizational policy?

Approved by (HR Benefits Administrator Name):

Reason for denial and next steps for employee:

Facilities Director Approval: Are all access provisioning requirements met and can keycard/locker credentials be issued?

Approved by (Facilities Director Name):

Outstanding issues preventing access provisioning:

Fitness Center Access Effective Date

Access Expiration/Renewal Date (if applicable)

Special Conditions, Restrictions, or Notes (e.g., temporary restrictions, required supervision, modified access hours):

HR Benefits Administrator Digital Signature

Facilities Director Digital Signature

Employee Acknowledgment Signature (confirming all information provided is accurate)

Final Approval Timestamp