Welcome To Your WellZone

Transcription

1 Welcome To Your WellZone Maximize Your Well Life Did you know that 1 in 3 US Adults doesn t exercise at all? But even moderate exercise a few days a week is great for you. It lowers your stress, cholesterol and weight, improves circulation, increases your metabolism and strength and recharges you with more energy. And that s just the beginning. Exercise is essential to your well being. Features: 17,500 Sq. Ft. Facility Full Court Gym Two Group Exercise Rooms Group exercise classes: kickboxing, step, cycling, group strength training, boot camp, yoga, pilates and interval training with more to come. Personal Training Available Massage Therapy Available Towel Service Welcome to your WellZone a full-service fitness facility from Halliburton located here at Oak Park. It s convenient, affordable and best of all built just for you regardless of your shape, size or current abilities. We re here to help you reach your personal goals and achieve optimal health. So sign up today and maximize your well life. Beth Sims and your friends at WellZone. Equipment: Free Weights Cybex & Hammer Strength Equipment LifeCycle Treadmills & Bikes Stair Master & Step Mill Trainers Elliptical Trainers Hours of Operation: 5:00 a.m. - 8:00 p.m 5:00 a.m. - 6:00 p.m. Closed Dues: No Registration Fee MON-THUR FRI SAT & SUN Halliburton employees, spouses and dependents over age 16 - $15 per person per month Halliburton retirees - $15 per person per month Non-employees (Halliburton contractors, and Oak Park Campus Occupants) - $20 per person per month Maximize Your Well Life WellZone Program Manager Beth Sims Beth has been in the fitness industry for 12 years. She received her Bachelor of Science degree in Kinesiology from Purdue and has her health/fitness instructor certification through The American College of Sports Medicine (ACSM). Beth has five years of corporate fitness experience at the YMCA and Chevron. She is dedicated to making WellZone one of the top corporate fitness sites a place for everyone to come and enjoy and maximize their well life.

2 Member Information Form Halliburton ID Badge Number: Member type: Halliburton employee, Spouse or dependent of Halliburton employee, Halliburton retiree, Non-Halliburton Employee (contractors, consultants, visitors) Halliburton Employee Sponsor: (if spouse or dependent of Halliburton employee) : Last Name: First Name: Gender ( Male Female) Age: Birth date: Halliburton Work Location (check or circle) Oak Park Northbelt The Woodlands Corporate Clinton Drive KBR Tower BMC Other: Work phone: ( ) - Work Home address: city state zip Home phone: ( ) - Mobile phone: ( ) - Home Emergency contact name: Emergency contact relationship: Emergency contact relationship phone 1: ( Emergency contact relationship phone 2: ( ) - ) -

3 Health Information Questionnaire Regular exercise is healthy and fun. For most people, physical activity should not pose any problem; however, some individuals should see their doctor prior to joining the program. Please answer all questions and return the completed form to the WellZone Fitness Staff. All information is kept strictly confidential by the WellZone Fitness staff and will be Name: of Birth (MM-DD-YYYY): / / Gender: M / F Age: Business Address: Work Phone: ( ) - Social Security No: - - Emergency Contact: Day Phone: ( ) - - Eve. Phone: ( ) - Doctor s Name Phone ( ) - of most recent doctor visit (M/YYYY): / DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING? Heart/Vascular Disease: Yes No Please Specify: Angina, chest pain (at rest or exertion) Coronary angioplasty or cardiac surgery Heart disease, heart attack Rapid heartbeats or palpitations Peripheral vascular disease Stroke Other (please indicate): Are you currently under your doctor s care for high blood pressure? Yes No Metabolic Disease: Yes No Please specify: Diabetes Kidney disease Thyroid or other Respiratory problems: Yes No Please specify: Asthma Emphysema or chronic obstructive lung disease (COPD) Other (please indicate): Seizure disorders or convulsions Yes No CORONARY RISK FACTORS Are you a male age 45 or above Yes No Are you a female age 55 or above Yes No Have your parents or siblings had a history of heart disease prior to age 55? Yes No Do you currently smoke or have you quit within the past 6 months? Yes No Within the past year, has your doctor told you that you have high cholesterol (greater than 240 mg/dl) Yes No If you marked YES to two (2) or more of the above, you must obtain your doctor s consent (Medical Clearance Form) prior to joining the WellZone Fitness Center WOMEN: Are you pregnant? Yes No If you marked YES to any of the above, you must obtain your doctor s consent (Medical Clearance Form) prior to joining the WellZone Fitness Center. Please check if you have any of the following conditions. These conditions may require medical consultation. Major surgery or hospitalization within the past 6 months. Please explain: Musculoskeletal/Joint problems (e.g. arthritis, back, shoulder, knees, etc.): Prescribed medications, please list those that you are taking: Do you have any other medical conditions or physical limitations that may affect participation in an exercise program? Please indicate: I verify that I have answered all questions truthfully and to the best of my knowledge. If I have a change in my health status during the course of my physical activity program, I will notify the Well Zone Staff immediately and provide information as requested. Signed: :

4 MEDICAL CLEARANCE for (Please print your name clearly) Note To Doctor - This individual would like to participate in a fitness program sponsored by WellZone. Based upon answers provided on the Health Information Questionnaire (see other side), we require doctor s clearance prior to program entry. It is the individual s responsibility to arrange and pay for any necessary charges associated with obtaining this medical clearance, including the cost of a physical exam or other testing. It is your decision whether to administer a graded exercise test (GXT) to your patient to evaluate the patient s capacity for regular exercise. PLEASE COMPLETE THE SECTION BELOW AND RETURN THE FORM TO THE INDIVIDUAL AT YOUR EARLIEST CONVENIENCE. Attach GXT results, if available. Description Of Program - Prior to beginning the exercise program, each member meets with a qualified fitness professional to discuss the individual s health history, program goals, and to obtain measurements of resting heart rate, blood pressure, height, and weight This information combined with your recommendations is used to develop an exercise program, which includes warm up, aerobic, strength, and flexibility exercises. Optional fitness screenings may include cardiovascular fitness capacity, flexibility, strength, and body composition. Screenings are not administered in the presence of a doctor and are not diagnostic in nature. Doctor s Recommendation - Check the appropriate box below and complete any associated questions. This individual may participate without restriction in all WellZone activities. This individual may participate in WellZone activities with the following limitations (Please Specify): Participation is not recommended at this time. If there is a MAXIMUM HEART RATE this individual should not exceed during exercise, please specify: beats/minute Medications: Physician Information (Please print) Name Work phone ( ) - Address Physician s Signature

5 Page 1 of 6 Halliburton Oak Park Fitness Center ( WellZone ) Membership Agreement As a member of WELLZONE, I acknowledge and agree as follows: 1. Non-discrimination I acknowledge WELLZONE, enrolls, and maintains memberships without regard to race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, sexual orientation or age. It is further facility policy that no circumstance or conduct undertaken by facility personnel shall have the effect of discrimination on the basis of any of the aforementioned classifications. All facility members shall have full and equal access to the facility. Any members with disabilities shall be entitled to reasonable accommodations for their physical and mental impairments. I agree that if I believe that I have been treated unfairly on any of the aforementioned matters that I will report such treatment to facility management or to the Halliburton Dispute Resolution Program ( DRP ) at (281) or (866) I further agree to resolve any and all disputes through the DRP, which includes binding arbitration as its final step. 2. PRIVACY STATEMENT WELLZONE, Medifit Corporate Services ( Medifit ), and all personnel associated with WELLZONE and its programs shall keep all personal information confidential and shall not release or provide any such information to a third party without the consent of the individual who is the subject of that information unless otherwise permitted to do so by applicable law. 3. PERSONAL INFORMATION I acknowledge that all the information required for a membership with WELLZONE is, to the best of my knowledge, true and accurate, and that I will notify WELLZONE of any changes within 10 business days of said change. 4. FACILITY RULES, GUIDELINES, AND PROCEDURES I agree to adhere to the rules, regulations, guidelines, and procedures of WELLZONE as may be adopted and published from time to time and understand and agree that such membership can be terminated by Halliburton Energy Services, Inc. or WELLZONE at any time for violation of WELLZONE rules, regulations, guidelines, and procedures, or for other business reasons. Facility rules, regulation, guidelines, and procedures may be changed at any time at the sole discretion of WELLZONE or Halliburton Energy Services, Inc. Member Initials

6 Page 2 of 6 5. DUES AND PAYROLL DEDECTIONS I understand that membership dues are $15.00 per calendar month per person for Halliburton Energy Services Inc. employees, their spouses, and eligible dependents age 16 and over and $20.00 per month per person for non-employees. I understand that the minimum membership term is one calendar month. If my join day is after the 15 th day of the month, I understand that my first payment of dues will be calculated as follows: 1 st month s dues, prorated at 50%, plus 2 nd month s dues. I understand that my dues are $ per calendar month (1 st to the 1 st ) per person and acknowledge such understanding by initialing here:. As a Halliburton Energy Services, Inc. employee, I authorize my employer to deduct monthly membership dues for me, my spouse, and eligible dependent members from my paycheck and I agree to sign a payroll deduction authorization form. I understand that monthly membership dues will remain the same until further notice and that Halliburton Energy Services, Inc. has the right to increase membership dues for future months at its sole discretion. As a spouse or dependent of a Halliburton Energy Services, Inc. employee, I understand that my dues will be paid via payroll deduction from the paycheck of the Halliburton employee of which I am a spouse or eligible dependent. I understand that monthly membership dues will remain the same until further notice and that Halliburton Energy Services, Inc. has the right to increase membership dues for future months at its sole discretion. As a non-employee, I understand that my membership shall automatically renew on a month-to-month basis and that I must continue to pay monthly dues via check and on or before the 1st of each month. I understand that dues are considered late if received later than the 5 th of each month. Late dues will be assessed a late fee of $ All checks for membership dues will be made payable to Halliburton and must be either presented in person to a staff member of WELLZONE or sent via mail to: Halliburton Attn: Fitness Center Manager, F Bellaire Houston, TX I understand that monthly membership dues will remain the same until further notice and that Halliburton Energy Services, Inc. has the right to increase membership dues for future months at its sole discretion. Member Initials

7 Page 3 of 6 6. MEMBERSHIP AUTOMATIC RENEWAL AND CANCELLATION As an employee, spouse, or dependent of an employee, I understand and agree that my membership shall automatically renew on a month-to-month basis unless or until I notify WELLZONE in writing that I wish to terminate my membership at least thirty (30) days prior to the expiration date. I acknowledge that in the event my membership is automatically renewed, payroll deductions will continue (including any increases) from the paycheck of the Halliburton employee. As a non-employee, I understand and agree that my membership shall automatically renew on a month-to-month basis and that I must continue to pay monthly dues on or before the first of each month. I understand that I must notify WELLZONE in writing that I wish to terminate my membership at least thirty (30) days prior to the expiration date and that I am responsible for amount due, including any increases or arrears, for membership until that date. 7. MEMBERSHIP CANCELLATION REFUNDS I understand that no refunds, whole or partial, will be granted for mid-month membership cancellation. 8. OTHER FEES AND PAYMENT METHODS I understand that certain activities included but not limited to massage therapy, personal training, specialty classes, and event entry fees are not included in my membership dues and will be paid via check to WELLZONE staff or as directed by WELLZONE staff. 9. RETURNED CHECKS I understand that a fee of $30.00 will be charged for each returned check and that WELLZONE, Medifit, and/or Halliburton Energy Services, Inc. may engage a collection agency to collect said fees and returned items, including the costs of collection. 10. IDENTIFICATION BADGES I will not permit any person other than myself to utilize my Halliburton Energy Services, Inc. issued identification badge to obtain entry to the WELLZONE facility. Violation of this policy will result in the immediate cancellation of my membership and permanent revocation of my facility use privileges, without refund of dues. 11. MEMBER CHECK-IN I will check-in at the facility front desk by swiping my identification badge across the identification badge reader each time I visit WELLZONE. If I do not have my identification badge, I will present myself to a WELLZONE staff member for check-in. 12. LOCKERS I will not leave any personal belongings in a locker overnight. I understand that any belongings left in a locker overnight will be removed and disposed of as refuse or donated to charity. I understand that WELLZONE and its staff are not responsible for any theft of, or damage to property I have deposited in a locker. Member Initials

8 Page 4 of DRESS CODE I will dress appropriately at all times while in the WELLZONE facility. I understand that jeans, cut-off shorts, halter tops, midriff exposing shirts or other items of clothing, thongs, shorts more than 8 inches above the knee, and low-cut tank tops are not appropriate attire and will not be permitted in the facility. I also understand that street shoes, cleats, or any other non-athletic shoes are not permitted in the group exercise rooms or gymnasium. I will carry a towel with me during workouts to protect and clean the equipment I use. 14. SOLICITATION I acknowledge that any solicitation within the facility is strictly forbidden. This includes, for example, solicitation for profit, political purposes, or any other reason. This includes, but is not limited to, use of petitions, distributing or posting leaflets, notices, or advertising anywhere in a club facility, or leaving multiple copies of leaflets or other papers in the facility. 15. UN-APPROVED PERSONAL TRAINING I understand that under no circumstances is any member to train another member for compensation. If it is determined, at the sole discretion of WELLZONE and/or Medifit staff, that un-approved paid personal training has been conducted in the facility, the trainer and trainee will lose their membership without any refund of dues. I understand that only individuals specifically approved and designated as personal trainers by Medifit may provide personal training services at WELLZONE. 16. USE OF ILLEGAL DRUGS OR ALCOHOL I will not use the facility while under the influence of illegal drugs or alcohol, nor will I bring any such items into the WELLZONE facility. 17. WEAPONS I understand that no weapons of any kind are permitted on the Halliburton Energy Services, Inc. property which includes WELLZONE and the surrounding Halliburton Oak Park Campus. 18. PHOTOGROPHY, TAPING, AND AUDIO RECORDING I understand that no photography, video taping, filming, or audio recording is permitted on WELLZONE premises without the express written permission of Halliburton Energy Services, Inc. Member Initials

9 Page 5 of INFORMED CONSENT AND RELEASE OF LIABILITY With respect to my use of the facilities and equipment at WELLZONE being managed by MediFit Corporate Services ( MediFit ), I understand that there may be health risks associated with activities requiring physical exertion, including but not limited to transient dizziness, fainting, nausea, muscle cramping, musculoskeletal injury, sprains and strains, heart attack, stroke or death. I certify that I am capable of performing physical exercise and acknowledge that I am voluntarily participating in any exercise activity available at the WELLZONE facility and that I am using equipment with knowledge of the dangers involved. I understand that I will be fully responsible for complying with any restrictions prescribed for me by my personal physician. I will review any personal fitness program with my physician prior to my commencing exercise and will periodically review my status and program with my physician. It is further understood that the WELLZONE staff will not be monitoring my individual use of the WELLZONE facility or exercise equipment available there. I understand that WELLZONE staff members are not medical professionals and have received training in physical activity programming for healthy individuals who do not require exercise in a medically supervised environment. If I experience any dizziness, fainting, nausea, muscle cramping or any other symptoms while exercising, I will discontinue the activity, notify the WELLZONE staff and consult my physician. In addition, I shall immediately cease using any equipment that appears to be malfunctioning and report it to a WELLZONE staff member. In the event there are any changes in my health status, such as medication change, recent illness or physical injury, I shall report that change to an appropriate WELLZONE staff member and shall wait to be cleared by the WELLZONE staff before resuming my activities at the WELLZONE facility or the use of its equipment. I further hereby fully release and hold harmless Halliburton Energy Services, Inc. its affiliates, officers, attorneys, directors, agents employees, contractors and all related subsidiaries, successors, and assigns and Medifit, its affiliates, officers, attorneys, directors, agents employees, contractors and all related subsidiaries, successors, and assigns from any and all liability, including, but not limited to, all claims, demands, actions, right of action, cause of action of whatsoever kind or nature, either in law or equity, arising from, relating to or by reason of my use of the WELLZONE facility and its equipment, including without limitation, any exercise program(s) therein, and hereby assume any and all risk and liability arising out of my use of the WELLZONE facility and its equipment as well as my participation in any exercise program therein. Member Initials

10 Page 6 of 6 This Informed Consent and Release of Liability shall be binding upon my heirs, spouse, or other next of kin, executor, administers and assigns. I acknowledge that I have read this Informed Consent and Release of Liability and that I am freely and voluntarily signing this membership contract. Printed Name Member Signature Number Member Identification Badge WELLZONE Staff Member Member Initials

11 MediFit Corporate Services HIPAA Notice of Privacy Practices for MediFit Managed Health and Fitness Centers Effective : April 14, 2003 This notice describes how protected health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Who Will Follow This Notice: This notice describes our privacy practices at MediFit managed health and fitness centers. Our Pledge Regarding Protected Health Information: We understand that health information about you is personal and we are committed to protecting your health information. We create a file for all members in order to provide you with quality service and to comply with legal requirements. This notice will tell you about the ways in which we use and disclose your health information. We also describe your rights and the obligations we have regarding the use and disclosure of health information. We are required by law to make sure that health information that identifies you is kept private; give you this notice of our privacy practices with respect to your health information; and follow the terms of the current notice. How We May Use and Disclose Health Information About You: We may use information about you to provide you with a personal health and fitness program. We may disclose health information about you to professional fitness staff and others involved in your health and fitness program. We may use your name to send membership bills to you or your company; to send you information about the fitness center; for incentive, award, motivational, i.e. member of the month, and other programs or communications, including posting it on a bulletin board; unless you specifically object. We may contact you to provide appointment reminders, information about health and fitness program alternatives or other health and fitness center-related benefit and services that may be of interest to you. We may keep your work out information about you in an unsecured file cabinet unless you object. You can keep this information secure in your own locker if you desire a higher level of security. We will disclose information about you when required to do so by law, in a lawsuit, to worker s compensation, for public health, for health oversight activities or to the military if applicable. You have the following rights regarding medical information we maintain about you: Right to Inspect and Copy. You have the right to inspect and copy your medical information, including your member file. You must submit your request in writing. We may charge a fee for the costs of copying. We may deny your request to see and obtain copies of your health information in certain, very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed HIPAA Compliance Services, LLC Page 1 of 2 FORM0012 Unauthorized duplication or distribution without the express written consent of HIPAA-CS is prohibited.

12 Right to Amend. If you feel that your information is incorrect or incomplete, you may ask us to amend the information. You may request an amendment as long as the fitness center has this information. You must submit your request in writing. We may deny your request in certain circumstances. Right to an Accounting of Disclosures. You have the right to request a list of the accounting of disclosures we made of your medical information. You must submit your request in writing. Your first requested list within a year is free. Right to Request Restrictions. You have the right to request a restriction or limitation on the information we use or disclose about you for treatment, payment, and health care operations or to someone who is involved in your care or the payment for your care. We are not required to agree to your request. You must submit your request in writing. Right to Request Confidential Communications. You have the right to specify the manner in which you want us to communicate with you regarding your health information. You must submit your request in writing. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. You may obtain a copy of this notice at our website, Changes to this Notice: We reserve the right to change this notice and make the revised notice effective for information we already have about you as well as any future information. We will post a copy of the current notice in the fitness center lobby. Other Uses of Medical Information: Other uses and disclosures of information not covered by this notice will be made only with your written permission. You may revoke that permission in writing at any time. Understand that we are unable to take back any permitted disclosures, and that we are required to retain records of your care. Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint. To file a complaint with the office, or for any other questions regarding our privacy practices, please contact: MediFit Privacy Officer 99 Washington Street South Norwalk, CT (203) [email protected] 2003 HIPAA Compliance Services, LLC Page 2 of 2 FORM0012 Unauthorized duplication or distribution without the express written consent of HIPAA-CS is prohibited.

13 MEDIFIT HIPAA PRIVACY PRACTICES ACKNOWLEDGEMENT FORM I have received and read a copy of the MediFit HIPAA Notice of Privacy Practices. I understand that a copy is always available at any time either hard copy in the fitness center, or via the Internet at Signature Print Staff Note: Once this form is signed, please file in your designated, secure place.

14 Payroll Deduction Authorization Payroll Deduction Action (check only one): BEGIN PAYROLL DEDUCTION CHANGE PAYROLL DEDUCTION STOP PAYROLL DEDUCTION Employee Information: SAP ID#: Employee Name: Deduction Information: Initial Prorated Deduction (if applicable): $ Regular Deduction Amount: $ Start : Stop : Employee Authorization: I authorize Halliburton Energy Services, Inc. to execute the above payroll deduction action regarding membership dues for the Halliburton Oak Park Fitness Center, WellZone. I acknowledge this payroll deduction action will be effective on the pay period begin date closest to my join date and that each deduction will be taken on the first pay period each month. I understand that this payroll deduction action, once commenced, will continue until I provide a minimum of 30 days written notice to WellZone. I understand that no refunds, whole or partial, for membership dues will be given under any circumstances other than Halliburton Energy Services, Inc. payroll processing error. Signature