Summer 2017 Exercise Class Registration
Classes offered at the 'Highland' location will be held in a meeting room of The Highlander Hotel', 6200 Middle Fiskville Road. Please contact Gina Akin for more details. Gina.Akin@austincc.edu
Email address *
Your Name *
Your answer
Employee ID Number *
I.e. r0040803
Your answer
Work phone extension *
Your answer
ACC email address *
Your answer
Please select one exercise class below (complete a separate form for each additional class). Bring your own yoga mat to your yoga class. Bring light hand weights (3, 5 or 8 lbs) to the Boot Camp, Strength/Toning and Core classes. These are not provided by ACC. Check with your instructor on the first day. *
Employee Classification *
PARTICIPATORY WELLNESS PROGRAM - PARTICIPATION AND RELEASE FORM -- Please insert your full name under each section to indicate you have read and agree to the terms and conditions of this Wellness Participation and Release form.
Austin Community College District (ACC) provides a voluntary wellness program as a benefit to ACC employees. Employees are encouraged to conduct a health and wellness assessment prior to enrolling in courses or workshops. Information about the wellness program can be found at austincc.edu/wellness/ *
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ATTENDANCE POLICY
As a participant of the Wellness Program at Austin Community College, I agree to attend at least 70% of the classes in which I enroll. I understand that I will be billed a $50.00 fee if I do not attend at least 70% of the activities in which I enroll. The following exceptions are allowed: • Active military duty • Change in work schedule beyond employee’s control • Death of close family member • Family emergency • FMLA leave • Illness • Vacation • Other "good cause," as determined by the college’s Wellness Committee. The Wellness Committee will review requests that do not fit the above circumstances. This program is only available for all staffing-table, full-time and adjunct faculty employees. *
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PAYROLL AUTHORIZATION
PAYROLL AUTHORIZATION: I authorize Austin Community College District (ACC) to deduct a total of $50 from my paycheck if I do not attend at least 70% of the activities in which I enroll, in accordance with the Attendance Policy stated above. I understand that I will be notified that I have not attended at least 70% of the activities prior to the payroll deduction. I understand that if my employment is terminated for any reason with Austin Community College District (ACC) prior to finalizing the full payment, I agree that the remaining amount would be deducted from my final paycheck. *
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WAIVER/RELEASE
I, being 18 years of age or older, do hereby acknowledge that there may be risks of physical harm and injury inherent in Wellness Fitness activities. I hereby certify that I am in good health and that I know of no reason why I may not participate in wellness activities. I hereby assume all risks involved in Wellness activities and acknowledge that Workers Compensation benefits are not extended to me in my capacity as a Wellness Program participant. I hereby hold Austin Community College, its employees, officers, agents and representatives, and Board of Trustees harmless from any and all claims and demands for damages arising out of any injury that I may experience as a result of my participation in ACC’s wellness program. Additionally, wellness classes may occasionally be delayed, cancelled or interrupted within our shared ACC space. I recognize the need to cooperate in these situations and act in a professional manner. This release and waiver shall be binding on my agents, heirs, administrators, and assigns. *
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I have read and agree to the terms and conditions of this Wellness Participation and Release form. Please insert your complete name below. *
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