Fill and Sign the F3520 2014 2019 Form

U.S. Fish and Wildlife Service Fitness Membership Fee Reimbursement Program Application Form Informed Consent Waiver: I wish to participate in the U.S. Fish and Wildlife Service’s Fitness Membership Fee Reimbursement Program. I agree to abide by Service rules and regulations and understand that violation of the rules will result in withdrawal of the taxable reimbursement available to me. I realize that there are inherent dangers whenever one engages in physical activity. I therefore accept all responsibility and assume the risk of injury or damage to my person that may arise, whether directly or indirectly, as a result of my participation in my fitness program. I hereby release and hold harmless from any liability whatsoever the U.S. Fish and Wildlife Service or the Department of the Interior, as well as its supervisors and representatives. I have been advised that a medical examination is recommended prior to engaging in a fitness program and that I am financially responsible for that medical examination. __________ initial I certify that there are no federally sponsored centers available to me, or that the federally sponsored fitness centers do not meet my needs for a fitness center for the following reason(s): __________ initial I certify that I have read Director’s Order 122 on this subject and the contents of this application form and understand their contents. Employee Name:(print)___________________________________________________ Employee Signature:_______________________________ Date:_________________ Supervisor Signature:_______________________________Date:_________________ Form 3-2178 04/00