Wellness and Fitness Center Registration Form Date: June 2009 Rev 2

Wellness and Fitness Center Registration Form Elyria, OH

Send this form to Shanna Dunbar, RN, COHN-S via email or interoffice mail. Mail code: M24

Name: E-ID#: Dept./Location: Please check one: Full Time Employee Part Time Employee Co-op or Summer Student (List dates of employment _________________________) Family Member or Guest of employee (list employee: ____________________) Retiree Furloughed Employee The following are available Bendix Wellness resources: Fitness Room - Weights, Cardio Equipment, Machines Cardio Room – Classes, Aerobic Programs, aerobic equipment, workout videos Skating/Rock Climbing Wall Walking Track Other activities promoted through the Health and Productivity committee and the wellness Team shall be communicated and posted through the BCVS intranet. Locker Rental Limited lockers are available for full-time rental in both the men's and women's locker rooms. Yearly rental fees will be established for 15 units in each locker room. Over registration will result in a lottery. Contact Jennifer Ackley at ext 9427. Wellness and Fitness Center Orientation All individuals requesting membership shall read the following documents before being allowed to utilize the wellness and fitness center.

Wellness and Fitness Center Operating Manual Wellness and Fitness Center Exercise Guidelines

I sign that I have reviewed the above checked documents and agree to abide by the established rules. Signature of user Date By signing this form, you agree to receive regular updates and announcements on wellness activities. If you do not wish to receive such communications, please check the following box.

I DO NOT wish to be notified of any upcoming wellness events