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Staff Benefits

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Staff Benefits and Wellbeing

Additional Member Amendment Form -Scarborough Hospital Onsite Gym

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First 5 digits on the back of your Trust ID Badge*

Please choose one of the following*

Personal Details

Full Name*

Email Address*

Assignment Number*

Department*

Amendments and cancellations of additional members.

Additional Member No.1

Name and Date of Birth

Changing room requirements

First 5 digits on ID badge (if applicable)

Choose one of the following

Additional Member No.2

Name and Date of Birth

Changing room requirements

First 5 digits on ID badge (if applicable)

Choose one of the following

Additional Member No.3

Name and Date of Birth

Changing room requirements

First 5 digits on ID badge (if applicable)

Choose one of the following

Additional Member No.4

Name and Date of Birth

Changing room requirements

First 5 digits on ID badge (if applicable)

Choose one of the following

Payroll Deduction (only complete if you are paying through your salary)

By checking this box, I authorise York and Scarborough Teaching Hospital NHS Foundation Trust to deduct/ cancel the following amount from my salary each month from the next available salary.*

Total deduction*

Decleration

I confirm I have read and are in agreement with the below declaration.*

Email 2*:

* required fields

Please read the following before submitting the above form:

• I understand that this is an unmanned gym.
• I agree to abide by the rules and regulations of the gym and squash court (full details available on the Staff Benefits website)
• I understand it is my responsibility to ensure any additional members adhere to the rules and regulations and the points raised in this declaration.
• I understand that it is my responsibility to maintain my own safety at all times whilst using the facility
• I understand that it is my responsibility to seek advice from my GP before undertaking any form of exercise
• I agree to accept fully the responsibility for any loss/injury/death caused by the result of using the equipment.
• I understand that I do not have to undertake an induction and that I can contact my own Instructor/Personal Trainer to arrange this if needed.
• I understand that any abuse of the facility will result in my membership being revoked
• I understand that any additional members I sign up will only be able to use the gym with me unless they hold a valid Trust badge of their own.
• All information on this form is protected by the new GDPR rules.
• Members under the age of 18 must be accompanied by an adult paying member when using the gym.


Please note this form must be with the Staff Benefits Team by the 1st of every month in order to give enough time for processing with the payroll team before payroll cut off. Any forms received after the 1st of the month may not be processed in time and may incur a charge.

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