Skip to Main Content
Do Not Show Again
How Do I...
You Are Here:
Select a Category
Administration & Council
Arts Grants / Galleries
Human Resources - Job Applications
Liberty Animal Shelter
Liberty Community Christmas Tree
Liberty Community Emergency Response Team (CERT)
Meals on Wheels
Parks and Recreation Forms
Public Relations Forms
Request the LFD Honor Guard
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
Sign in to Save Progress
2021 Employee Wellness LCC Visit Pass report request
This form has been modified since it was saved. Please review all fields before submitting.
More information about all Employee wellness programs is available online >> www.libertymissouri.gov/EmployeeWellness.
Employee ID #
Primary City Department
What My Impact Incentive Programs would you like to see in the future?
How has the My Impact Incentive program improved your attention to wellness?
I have agreed to participate voluntarily, and not as a condition of employment, in wellness programming under the guidance of Liberty Parks & Recreation, its authorized agents, employees, and contractors. I understand this information shared in the above form as well during programming will remain confidential.
I am over the age of 18 and acknowledge I have been informed of the need for a physician’s approval for my participation in wellness programming. I acknowledge I have either had a physical examination and been given my physician’s permission to participate, or if I have chosen not to obtain a physician’s permission prior to beginning this wellness program, I acknowledge I am doing so at my own risk.
Further, I authorize Liberty Parks & Recreation staff to seek emergency medical treatment on my behalf if such treatment is necessary as a result of an injury I receive in a wellness program. Participation in health and wellness programming may involve the sharing of personal health information with other individuals, including other city employees. I understand that the exchange of such information is not covered by HIPAA and is voluntary. I understand and am aware that health and wellness programming includes potentially risky activities. I am voluntarily participating in these activities with knowledge of the potential risks. I hereby agree to hold harmless Liberty Parks & Recreation, its respective representatives, executors, agents, and assigns from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected to my participation in any and all wellness programming.
I acknowledge I have thoroughly read this waiver and release and fully understand it is a waiver and release of liability. By signing this document, I am waiving any right I, or my heirs and/or assigns, may have to bring any and all legal actions or assert any and all claims against Liberty Parks & Recreation, its respective representatives, executors, and/or assigns.
I have read the above information and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
Leave This Blank:
Receive an email copy of this form.
This field is not part of the form submission.
* indicates a required field
How Do I...
Slideshow Left Arrow
Slideshow Right Arrow