Request Form For Title 10 Independent Duty Personnel (Idp) Fitness Memberships Respite Care Authorization

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MONTHLY RATE CHARGE $______ x 6 = $__________
Request for Title 10 Independent Duty Personnel (IDP)
Fitness Memberships/Respite Care Authorization
Command Name________________________________________________________________
Address_______________________________________________________________________
City__________________________________________ State__________ Zip_______________
Duty Address if different from Command Address: ____________________________________
______________________________________________________________________________
Command fitness membership Point of Contact __________________________________
Phone ________________Fax__________________E-mail______________________________
Number of active duty personnel eligible to participate (Title 10 Only): ___
Number of personnel requesting single fitness membership at a private fitness facility: ___
Name/Address/Phone number of Private Fitness facility of choice:
(All members in the command MUST attend the same private facility)
__________________________________________________________ Phone ___________
Rate/Rank/Full Name of each Service member (Please print legibly):
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
Number of personnel requesting YMCA memberships: ___
Rate/Rank/Full Name of each Service member (Please print legibly):
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
The following statement must be on each request and signed by the Commanding Officer or
Officer in Charge if no Commanding Officer assigned:
I understand only Title 10 personnel are eligible and certify that no Title 32 personnel are included in this
request. I also certify the above named active duty personnel are assigned to this command and will be for a
minimum of six months. This command does not pay for fitness memberships for our personnel and this
command does not have access to a free fitness facility at or near this location.
I will ensure all personnel understand the minimum usage of either the YMCA or private fitness facility is 8
times per month and no renewal will be authorized for any personnel not meeting this minimum usage
requirement.
__________________________________________________
Printed Name/Title of Signature of Commanding Officer
____________________________________________________________________________________________________
This section to be used by Services’ Point of Contact (see attached list for authorized signatures)
Request for Independent Duty Personnel fitness memberships is approved / disapproved. The
above named personnel are also authorized Respite Child Care at YMCAs that meet DOD
criteria.
__________________________________________________
Service POC signature
Copy to: ASYMCA and Requesting Command

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