Health Club Membership Reimbursement Policy and Request

[Company] recognizes that physical fitness contributes to the health, productivity, and well-being of employees. To help employees keep healthy and fit, we will contribute toward payments for health club and Y memberships, as follows.

Employees who join a health club, Y, gymnasium, tennis club, or another acceptable fitness improvement organization will be reimbursed one-half the annual cost of an individual membership, up to a maximum of $[300.00] in any one year. A list of some eligible organizations in the local community appears below. Employees wishing to join other organizations should consult the human resources department before joining, to learn whether the membership will be eligible for reimbursement. Employees may enroll in more than one organization, provided the total amount requested from the company is no more than the $[300.00] per year maximum. Purchases of personal equipment will not be reimbursed. Employees who buy family memberships will be reimbursed for half the cost of an individual membership, unless there is more than one employee in the family.

All employees are eligible. Once you have joined and paid for your membership, complete the attached form and send it to the human resources department, along with a copy of your check or receipt.

List of eligible organizations

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Health Club Membership Reimbursement

Employee Name: ______Social Security #: ______

Department: ______Hire Date: ______

I have enrolled in the following physical fitness organization:

Organization: ______

Location: ______

My membership for ______months/years costs $______and is  for myself only  for myself and my family. Had I bought a one-year individual membership offering the same benefits and privileges, the cost to me, after deducting any discounts for which I would have been eligible at the time, would have been $______. The membership starts on ______and continues through ______, 20____.

I  have  have not requested reimbursement for other memberships that overlap this one.

I wish to be reimbursed by the company to the extent allowed under the health club membership reimbursement policy. My receipt is attached.

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Employee Date