Dan Abraham Healthy Living Center New Member Form

Responsible Employee Information

This will be the responsible Employee for the membership
Employee ID*
Employee First Name*
Employee Middle Name
Employee Last Name*
Employee E-mail*
Email must be Mayo Email: example@mayo.edu

Joining Member Information
Member Employee ID (If exists)
Member First Name*
Member Middle Name
Member Last Name*
Member Gender Assigned at Birth*

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Member Email*
example@example.com
Member Date of Birth*

MonthDayYear
Date
Current Date

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Date
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I attest that my dependent has a documented mental or physical condition that qualifies them for Adult Dependent status.”*

Confirm Eligibility
Members must be older than 18
Member Phone Number*
Please enter a valid phone number.
Member Address*

Street Address

Street Address Line 2

CityState

Zip Code

Emergency Contacts
Emergency Contact*
Emergency Contact Phone*
Please enter a valid phone number.

Research Release

Research Notification for Dan Abraham Healthy Living Center (DAHLC) Members
It is important to the DAHLC that all members are informed about how their information may be used, including use for quality improvement, evaluation, and research that will contribute to future advances in health and wellness. As a courtesy to members, we are providing this update.

We use the following information at the DAHLC: demographics like age and gender, DAHLC survey responses, and facility use contained in the DAHLC database — this is not connected to your medical record. Our projects are often related to program offerings and potential barriers to a healthy lifestyle.

You may be asked to participate in specific studies in the future, and you may continue to receive general surveys, even if you opt out of research. DAHLC will continue to protect your privacy, identity, and confidentiality through strict de-identification processes. This includes removal of identifiers that could be linked to a single individual. Only group data are published in studies, never individual identifiers. Not responding to this notification means that DAHLC will continue to use your data for quality improvement, evaluation, and research. You have the right to decline the use of your information for these purposes. Your decision will not affect the service you receive at DAHLC or care at Mayo Clinic. You can withdraw your permission at any time by sending a dated and signed letter to: DAHLC Research, DA-1-230, 200 First Street SW, Rochester, MN
55905.

If you have any questions or concerns about this notification, contact us at dahlcresearch@mayo.edu.
Research Notification Acknowledgement*

Membership Agreement: Liability Release and Waiver
In consideration of being allowed to participate in the activities and programs of the Dan Abraham Healthy Living Center and to use its facilities and equipment in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge Dan Abraham Healthy Living Center, Mayo Clinic, and their officers, agents, employees, representatives, executors, and all others (Mayo Clinic representatives) from any and all responsibilities or liabilities from injuries or damages arriving out of or connected with my attendance at Dan Abraham Healthy Living Center, my participation in all activities, my use of equipment, or any act or omission.

I hereby acknowledge that members’ use of Dan Abraham Healthy Living Center facilities and equipment, and participation in activities and programs are at their own risk.

Additional Notices and Disclaimers

• Members should consult their personal provider before beginning a course of exercise or wellness program. Be advised that a provider does not review this registration form or any health information contained in the registration form.
• If you receive patient care related services at Dan Abraham Healthy Living Center, clinical information about those services may be documented in your Mayo Clinic medical record.
• The Saint Marys Dan Abraham Healthy Living Center campus facility is a self-service facility, open 24 hours per day, 7 days per week; no guests permitted.
• If the agreement is signed fraudulently, member fails to demonstrate Mayo Clinic’s RICH TIES or adhere to institutional policies, you risk losing your Dan Abraham Healthy Living Center membership and other potential employment benefits with Mayo Clinic.
• As a Mayo Clinic employee, your children age 18+ are eligible for membership if they meet IRS Tax Dependency Guidelines. Your signature verifies this is an adult child of yours and is a dependent as defined by the IRS. If you are unsure, reference Internal Revenue code section 152.
• The member has the responsibility to notify Dan Abraham Healthy Living Center when a dependent student no longer meets IRS criteria.

The following signature consents to waiver of liability, member policies, research notification, and authorizes MFMER to implement payroll deduction for membership fees for eligible employees. Membership dues and fees are the responsibility of the member.
Printed Name of New Member (First, Middle, Last)*
Enter Member Name
Date*

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License Plate and Vehicle Information

To access DAHLC parking spaces, the following fields are required:
Will you be registering a vehicle?*

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Employee Vehicle Information already on file
State Vehicle Registered in*
Plate Number*
Confirm Plate Number*
Plate Number and Confirm Plate Number don't match or aren't entered.
Year*
Make*
Model*
Color*
Should be Empty:

Dan Abraham Healthy Living Center

Responsible Employee Information

Joining Member Information

Emergency Contacts

Research Release

Membership Agreement: Liability Release and Waiver

License Plate and Vehicle Information