Complete Your Fitness Center Access Registration

Employee ID Number

Full Legal Name (as per official records)

Department/Division

Job Title/Role

Work Email Address

Work Phone/Extension

Employment Status

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 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?

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

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

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

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

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

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?

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

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?

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 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

Requested Access Level

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

Do you wish to rent a personal locker?

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?

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

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

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