Liability Waiver and Informed Consent Form

2020 City of Topeka Fitness Center Liability Waiver/Informed Consent Form

Name Work/Cell Phone Email

City of Topeka Employee Employee ID Department

City of Topeka Retiree Address

Dependent of City of Topeka Employee Spouse OR Child (Age 14-15, 16-17, 18-25)

Shawnee County Employee

Last 4 digits of SS # (necessary for providing badge access)

Requested Access Start Date: Requested Access End Date:

Emergency contact name Emergency contact Phone:

VOLUNTARY: I have voluntarily chosen to use, or allow my spouse or child age 14+ to use the exercise equipment and/or participate in a fitness program offered through the City of Topeka. I understand that activities available through the Fitness Program are not part of my job responsibilities and must be performed on my own time. I understand and agree to be physically present with and supervise activities of my dependent(s) if age 14-15.

RISK: I recognize that use of the facility or enrollment in any program may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular training, and other various fitness activities, all of which are not medically supervised. I understand that any exercise or fitness activity involves a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death. I am accepting such risks and volunteering to participate with full understanding of the dangers involved. I understand that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed. If I have chosen not to obtain consent from a personal healthcare provider prior to beginning this fitness program, I hereby agree that I am doing so solely at my own risk and that it is my sole responsibility to participate in exercises that are appropriate for the current health status. If I have any questions or concerns if an activity is appropriate to my current health status, I understand it is my responsibility to ask my personal healthcare provider before I participate in such activity.

WAIVER: In consideration of my participation in this program, I, for myself and my heirs, assigns, and anyone entitled to act on my behalf, hereby waive and release the City of Topeka, its officials, employees, and their successors and assigns, from any and all claims, costs, liability and expense for any injury, loss or damage whether known, anticipated or unanticipated arising from my voluntary participation and enrollment.

2020 City of Topeka Fitness Center Facility Guidelines

Membership

• COT benefit eligible employees, and retirees may use fitness center at no cost.

• Dependents (spouses and children), over the age of 14 years may use the Fitness Center for $15 dollars per quarter. ($30 dollars per quarter for 2 or more dependents.)

• Qualified dependent children age 14-15 years old must be supervised by legal Parent or Guardian at all times.

• Membership is available to Shawnee County employees according to the City of Topeka/ Shawnee County Fitness Center Agreement. (Dependents of Shawnee County employees are not eligible at this time.)

Fitness Center Guidelines

• Members MUST sign in every time they use the Fitness Center.

• The City reserves the right to refuse usage based upon a prior failure to comply with the guidelines, who are abusive to staff or other members, for safety reasons, or for other reasonable and legal cause. All members must complete a Fitness Center Liability Waiver form and Health Risk Questionnaire each year.

• Dependents are required to complete enrollment forms and pay quarterly fees before being granted a badge with access.

• Dependent membership fees are due prior to the beginning of each quarter.

Unauthorized Use of Facility

• Only properly enrolled and eligible members are authorized to use the Fitness Center. Any employee who allows unauthorized use of the facility will lose access and may also be subject to disciplinary action.

Hours of Operation * Monday-Friday: 6 am-10 pm * Saturday & Sunday: 7 am-7 pm

Use of the Equipment

• The equipment is paid for with City funds. Please take care of it and maintain it appropriately.

• Each user must wipe down equipment with provided sanitizing wipes and put equipment away after use.

• Food and beverages, other than water, are not permitted.

• Please turn off select lights and TV/DVD player or radio if they are the last user to leave the facility after 5:00 p.m. or before 6:00 a.m.

• Any malfunctions must be reported immediately.

Locker Room/Shower Usage

• The Fitness Center is not responsible for lost or stolen items, please do not bring valuables.

• Remember to bring your own towel and pick up after yourself.

Dress

• Please dress appropriately, while promoting confidence, comfort and ease while using the facility. Users are required to wear appropriate athletic shoes and shirts during a workout.

• Users may wear business attire clothing on cardio equipment as long as appropriate footwear is worn.

Accidents/Notifications

• IN AN EMERGENCY CALL 911

• Contact the Wellness Coordinator of any incidents or accidents in the Fitness Center, or equipment and custodial issues that need to be addressed.

• If staff is unavailable, call the Guard Station (368.0999) or HR Desk (368.3867)

• For after business hours facility emergencies (ex: Flood) please call 785.633.5290.

Failure to adhere to these guidelines may result in a loss of your membership.

Emily Pham, Wellness Coordinator

epham@topeka.org    785.368.3602

Human Resources Department

785.368.3867