Staff Fitness & Nutrition Reimbursement Request Form

Home Staff Fitness & Nutrition Reimbursement Request Form

Fitness Club Reimbursement Request Form

Activity, Fitness Club & Weight Watchers Reimbursement Request Form

Staff Fitness Reimbursement Form

Overview: Submit form for reimbursement for 50% of fitness membership expenses and/or 50%. Reimbursement for out-of-pocket Nutrition Program expenses not to exceed $25 • Only 1 reimbursement request per employee, per month up to $25 will be paid for eligible full-time employees or family membership for family members residing within household • Part-time employees are eligible for single employee memberships only 1. Attend a fitness facility at least 8 times during the reimbursement month, or attend 3 Weight Watchers meetings during the reimbursement month. 3. Submit proof of payment and proof of attendance. 4. Submit your completed form by the 7th of the following month. Note: City of Muskegon fitness facilities are not eligible for reimbursement. This is a summarized online form for all details contact Dwana Thompson.

Employee Information

Name(Required)

First Last

Department:(Required)

Reimbursement Month:(Required)

Email(Required)

Daytime Phone(Required)

Membership Details

Type of Membership:(Required)

Fitness Facility

Weight Watchers or Dietitian Program

Drop In Classes or League Play

Fitness Facility or Program Name:(Required)

Membership Fee:(Required)

Monthly or Annual Fee

Monthly

Annual

Other

Amount of Reimbursement Requested (50% up to $25)(Required)

Required Uploads

Upload 1 – Visit Proof(Required)

Upload proof of attendance (e.g., gym visit log, check-in summary, or meeting attendance record).

Drop files here or

Max. file size: 300 MB.

Upload 2 – Payment Confirmation(Required)

Upload proof of payment (e.g., receipt, credit card statement showing gym name, or payment confirmation email).