Oxford Gym Reimbursement Form Page 2
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1
2Gym reimbursement form substitutes
The gym representative signature constitutes agreement
that the gym facility promotes cardiovascular wellness.
One of the following pieces of documentation may be
False statements will result in a denial of reimbursement.
used as a substitute for the Gym Reimbursement Form:
My signature below affirms that all of the information listed
(Note: Your documentation must include a signature
is full, complete and true to the best of my knowledge.
from a gym representative for verification purposes.)
• A photocopy of your fitness program card or your records
Member Name: ___________________________________
kept on file at the gym. An original signature must appear
on the photocopy (photocopied signatures are not valid)
Oxford ID Number: ________________________________
• A computer printout of your visits to the fitness center
• Receipts that indicate each time you have visited the gym
Member Address: _________________________________
or
Member Signature: ________________________________
• Verification from your employer that indicates your use
of the employer’s gym
Date: ___________________________________________
Name of Gym: __________________________________
Gym Representative Signature: ____________________
Date of visit:
Date of visit:
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If you have any questions regarding gym reimbursement, please
call Customer Service at 1-800-444-6222.
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