Fitness Membership Application & Agreement

Name: / Date of Birth: / //
Last / First / MI
Address:
Street Address / City, State, Zip
Home Phone: / Cell Phone:
Email Address: / Tribal ID:
Employer: / Work Phone:
Spouse Name: / Tribal ID:
Child(ren): Name / Age / DOB / Sex / Tribally Enrolled / Tribal ID:
// / Yes No
// / Yes No
// / Yes No
// / Yes No
// / Yes No
// / Yes No
Requested Facility:
Terms of Agreement:
  1. I/We agree to pay a $20 co-pay for the single membership or $30 co-pay for a family membership. Checks or money orders for co-pays made payable to: Ho-Chunk Healthcare Center (HHCC). Co-pays must be returned to the Health & Wellness staff at N6520 Lumberjack Guy Rd, Black River Falls, WI 54615.
  2. The co-pay will be waived if I complete one of the following courses: Pathway to Wellness, DM Basic’s, Smoking Cessation or approved DM Prevention classes. The only way this co-pay will be waived is if I complete one or more of these courses from beginning to end and all of the necessary labs and paperwork.
/ Initials:
  1. I/We agree to use the membership at least 10 times per month
/ Initials:
  1. Cancellation Policy: The membership is non-transferrable; co-pay is non-refundable. Contact the Wellness team to cancel membership.
/ Initials:
  1. RENEWAL
  1. Every 6 months members must provide a new Ho-Chunk Nation Fitness Membership application to the Health & Wellness staff.
  2. Every 6 months members must provide proof of utilization.
  3. The diabetes staff will attempt to contact participant 30 days prior to membership ending. Members will have 15 days to contact staff and provide required documentation.
  4. Documentation needed for consideration of renewal:
  5. Ho-Chunk Fitness Membership Application.
  6. Co-pay
  7. Utilization report from facility.
  8. Renewals will be categorized as follows:
  9. Primary cardholder and approved family members used the facility an average of ≥ 10 times per month. There will be no co-pay required.
  10. Primary cardholder and approved family members used the facility an average of 5-10 times per month. Co-pay will continue ($20.00 for individual and $30.00 for family). Approved family members for a family membership are a Ho-Chunk enrolled spouse and/or Ho-Chunk enrolled children.
  11. Primary cardholder and approved family members used facility an average of 1-4 times the co-pay will be double to renew membership. ($40.00 for individual and $60.00 for family)
  12. Primary cardholder and approved family members used the facility less than one time per month the membership will be put on suspension for 6 months.
/ Initials:
  1. I will be liable for any property damage or personal injury to myself and/or my family while using this membership.
/ Initials:
  1. Any deposits required by the facility will be the responsibility of the participant.
/ Initials:
  1. To be eligible for a family membership the family members must be either a Ho-Chunk enrolled spouse or Ho-Chunk enrolled children under the age of 18.
/ Initials:
  1. Applications and guidelines are subject to change at any time for any reason by the Health & Wellness staff.
  2. Any incomplete (any missing information/paperwork) applications greater than 6 months old from the signature date will be shredded and considered expired. A new membership enrollment process will need to be started after the six months if participant is still interested.
/ Initials:
Initials:
I/We agree to accept and abide by the terms of this Membership Agreement. I/We understand the Membership agreement is for a term of six (6) months.
Signed: / Dated:

December 12, 2013