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2. First Name*
3. Last Name*
5. Employee ID #*
6. Email Address*
8. Primary City Department*
12. Please rate your perceived current physical activity level:*

    1. Sedentary(engage only in activities of daily living)
    2. Lightly Active (30 minutes a day of moderate aerobic activity)
    3. Moderately Active (60 minutes a day of moderate aerobic activity)
    4. Very Active (1.5 hours or more daily of moderate aerobic activity)
14. How important is physical fitness in your life?*

    1. Not Important
    2. Somewhat Important
    3. Very Important
    4. Crucial
16. Please cite your current perceived level of stress from 0-10, with 0 being no stress and 10 being high stress.*

    1. 0
    2. 1
    3. 2
    4. 3
    5. 4
    6. 5

    1. 6
    2. 7
    3. 8
    4. 9
    5. 10
18. I believe that I have a working knowledge of how to safely perform a variety of physical fitness exercises.*

    1. Yes, I strongly agree
    2. Yes, I agree
    3. No, I disagree
    4. No, I strongly disagree
    5. I do not know how to safely perform various physical fitness exercises.
20. How did you hear about this program?*

    1. Employee Wellness Email
    2. Employee Wellness Website
    3. Word of Mouth
    4. From a Co-Worker
    5. Wellness Staff
    6. Other
22. If other, please specify
26. I have agreed to participate voluntarily, and not as a condition of employment, in wellness programming under the guidance of Liberty Parks & Recreation, its authorized agents, employees, and contractors. I understand this information shared in the above form as well during programming will remain confidential.*

    1. I agree
28. Participant Waiver*

    1. I agree

    I am over the age of 18 and acknowledge I have been informed of the need for a physician’s approval for my participation in wellness programming. I acknowledge I have either had a physical examination and been given my physician’s permission to participate, or if I have chosen not to obtain a physician’s permission prior to beginning this wellness program, I acknowledge I am doing so at my own risk.

    Further, I authorize Liberty Parks & Recreation staff to seek emergency medical treatment on my behalf if such treatment is necessary as a result of an injury I receive in a wellness program. Participation in health and wellness programming may involve the sharing of personal health information with other individuals, including other city employees. I understand that the exchange of such information is not covered by HIPAA and is voluntary. I understand and am aware that health and wellness programming includes potentially risky activities. I am voluntarily participating in these activities with knowledge of the potential risks. I hereby agree to hold harmless Liberty Parks & Recreation, its respective representatives, executors, agents, and assigns from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected to my participation in any and all wellness programming.

    I acknowledge I have thoroughly read this waiver and release and fully understand it is a waiver and release of liability. By signing this document, I am waiving any right I, or my heirs and/or assigns, may have to bring any and all legal actions or assert any and all claims against Liberty Parks & Recreation, its respective representatives, executors, and/or assigns.

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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field