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Wellness Fitness Release Time

Approved Physical Fitness Activity Application:

This application should be completed by the person who will be the leader/organizer responsible for overseeing the activity. This person must track attendance and provide reporting as requested.  Please complete the document in its entirety and indicate  agreement with the statement below.  Thank you.

 

Click here for the Fitness Release Time Guidelines.

 

Organizer (Individual or Department) 

Program Leader/Contact Person 

Title 

Email 

Office & Building Address

Phone Number

 

 

Organizer’s supervisor

Supervisor email 

Supervisor phone number 

 

 

Activity Name 

Program Description 

Who may participate

Number of expected participants 

What days and times will the program occur 

Where will the program occur

When will the overall program begin

If applicable, please indicate the end date for the activity

How will it be promoted

How will an employee’s participation be tracked/verified

Who will oversee the recording/reporting of employees’ attendance

 

 

  I understand that employees participating in this activity must sign-in/track their participation/attendance. Furthermore, I understand that as the leader/organizer of the activity, it is my responsibility to take and keep record of attendance and to provide reporting for verification of employee participation as requested.

  I understand that Failure to implement this requirement for the activity and/or misuse of the FRT by employees may result in a discontinuation of the Approved Physical Fitness Activity, revocation of an employee’s approval to participate in FRT and corrective action up to and including termination of employment as indicated in the FRT and Wellness Leave Policy.

 

By typing your name in the Electronic Signature field and submitting this form, you agree to the above 2 statements.

 

Electronic Signature   

Date