{"id":240,"date":"2017-06-02T16:43:16","date_gmt":"2017-06-02T16:43:16","guid":{"rendered":"http:\/\/forms.westernu.edu\/students\/?page_id=240"},"modified":"2026-03-20T18:25:39","modified_gmt":"2026-03-20T18:25:39","slug":"gym-membership-reimbursement-form","status":"publish","type":"page","link":"https:\/\/forms.westernu.edu\/students\/gym-membership-reimbursement-form\/","title":{"rendered":"Gym Membership Reimbursement Form"},"content":{"rendered":"<p>If you pay monthly for your membership, we will reopen the form in the Spring.\u00a0 As a reminder, you must have an active membership for at least 10-consecutive months during the current academic year to qualify. Specifically July-April, August-May, or September-June.<\/p>\r\n<p>All paperwork due by the deadline below (depending on how you pay for your membership):<\/p>\r\n<ul>\r\n<li><strong>Annually\/Prepaid<\/strong> &#8211; Deadline: <strong>September 1, 2025<\/strong><\/li>\r\n<li><strong>Monthly<\/strong> &#8211; Deadline: <strong>June 1, 2026<\/strong>\u00a0<em>(i.e. AFTER you&#8217;ve paid for 10 consecutive months within the current academic year)<\/em><\/li>\r\n<\/ul>\r\n<p>If your membership is &#8220;off-cycle&#8221; and you&#8217;ve renewed mid-year, please contact <a href=\"mailto:studentaffairs@westernu.edu\">studentaffairs@westernu.edu<\/a> to determine if you qualify for the up to $100 reimbursement.\u00a0<\/p>\r\n\r\n<p style=\"text-align: left;\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_71' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_71'  action='\/students\/wp-json\/wp\/v2\/pages\/240' data-formid='71' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_71' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_71_65\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br><\/li><li id=\"field_71_64\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">AT THIS TIME: Only Accepting Month-to-Month Requests<\/h2><div class='gsection_description' id='gfield_description_71_64'>If you pay annually for your membership, the deadline for the 2025-2026 AY was September 1, 2025. Please also note, you are only eligible if you have an active membership for at least 10 CONSECUTIVE MONTHS during the current academic year. Specifically, this includes an active membership for following periods: July-April, August-May, and September-June.<\/div><\/li><li id=\"field_71_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h2 class=\"gsection_title\">AT THIS TIME: Only Accepting Annual Pre-Paid Requests<\/h2><div class='gsection_description' id='gfield_description_71_67'>If you pay monthly for your membership please wait until you've paid for 10 CONSECUTIVE MONTHS (specifically, this includes an active membership for following periods: July-April, August-May, and September-June) and then submit your request.  Deadline for the 2025-2026 AY is June 1, 2026. <\/div><\/li><li id=\"field_71_66\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br>\n<br>\n<br><\/li><li id=\"field_71_2\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >WesternU may reimburse you up to $100 for your fitness membership. Only current students are eligible for this benefit<br \/>\n<br \/>\n<b>YOU WILL NOT BE ELIGIBLE FOR REIMBURSEMENT IF YOU HAVE A MEMBERSHIP TO SAMFIT. By purchasing a SamFit membership through WesternU, the membership is already subsidized by $100.<\/b>\n<\/li><li id=\"field_71_38\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_72\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >We process hundreds of reimbursement request. To help ensure you have the required documents, please answer the questions below:<\/li><li id=\"field_71_73\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >This request is for academic year (July-June)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_71_37'>\n\t\t\t<li class='gchoice gchoice_71_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='2025-2026'  id='choice_71_37_0'    \/>\n\t\t\t\t<label for='choice_71_37_0' id='label_71_37_0' class='gform-field-label gform-field-label--type-inline'>2025-2026<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_37_1'>\n\t\t\t\t<input name='input_37' type='radio' value='No'  id='choice_71_37_1'    \/>\n\t\t\t\t<label for='choice_71_37_1' id='label_71_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_71_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have proof the membership is in your name?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_71_71'>If you do not have proof the membership is in your name, please contact your gym or login and find a contract\/document showing your name and the gym. <\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_71_71'>\n\t\t\t<li class='gchoice gchoice_71_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='Yes'  id='choice_71_71_0'    \/>\n\t\t\t\t<label for='choice_71_71_0' id='label_71_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='No'  id='choice_71_71_1'    \/>\n\t\t\t\t<label for='choice_71_71_1' id='label_71_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_71_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have proof of membership dates AND payment for 10-months of the current academic year (July-June)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_71_74'>If you do not have proof, please contact your gym or login and find a contract\/document\/payment history showing your membership start\/end dates and payment(s). If you pay annually, we need proof of your one payment plus membership start\/end dates. If you pay monthly, we need proof of all 10 months of payment\/membership. In either case, the proof of payment must also include your name. <\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_71_74'>\n\t\t\t<li class='gchoice gchoice_71_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='Yes'  id='choice_71_74_0'    \/>\n\t\t\t\t<label for='choice_71_74_0' id='label_71_74_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='No'  id='choice_71_74_1'    \/>\n\t\t\t\t<label for='choice_71_74_1' id='label_71_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_71_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you merged all of your documents into one .pdf?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_71_75'>Multiple-page upload is not allowed on the next screen so please merge everything into one .pdf. <\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_71_75'>\n\t\t\t<li class='gchoice gchoice_71_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='Yes'  id='choice_71_75_0'    \/>\n\t\t\t\t<label for='choice_71_75_0' id='label_71_75_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='No'  id='choice_71_75_1'    \/>\n\t\t\t\t<label for='choice_71_75_1' id='label_71_75_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_71_77\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >If you answered \"no\" to any of the above questions. You will not be able to proceed to the next page.  Please gather the necessary documents and then submit. <\/li><li id=\"field_71_45\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_79\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Your Information<\/h2><\/li><li id=\"field_71_80\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_71_5'>\n                            \n                            <span id='input_71_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_71_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_71_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_71_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_71_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_71_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_71_6\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Current Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_71_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_71_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_71_6_1' value=''    aria-required='true'    \/>\n                                        <label for='input_71_6_1' id='input_71_6_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_71_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_71_6_2' value=''     aria-required='false'   \/>\n                                        <label for='input_71_6_2' id='input_71_6_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_71_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_71_6_3' value=''    aria-required='true'    \/>\n                                    <label for='input_71_6_3' id='input_71_6_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_71_6_4_container' >\n                                        <input type='text' name='input_6.4' id='input_71_6_4' value=''      aria-required='true'    \/>\n                                        <label for='input_71_6_4' id='input_71_6_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_71_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_71_6_5' value=''    aria-required='true'    \/>\n                                    <label for='input_71_6_5' id='input_71_6_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_71_6_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_71_8\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_71_8'>Student ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_71_8' type='text' value='' class='medium' maxlength='9'   placeholder='Include &#039;@&#039;' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_71_9\" class=\"gfield gfield--type-select gfield--input-type-select gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_71_9'>Program<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_71_9' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select One' selected='selected'>Select One<\/option><option value='Doctor of Dental Medicine' >Doctor of Dental Medicine<\/option><option value='Doctor of Optometry' >Doctor of Optometry<\/option><option value='Doctor of Osteopathic Medicine' >Doctor of Osteopathic Medicine<\/option><option value='Doctor of Osteopathic Medicine-Northwest' >Doctor of Osteopathic Medicine-Northwest<\/option><option value='Doctor of Pharmacy' >Doctor of Pharmacy<\/option><option value='Doctor of Physical Therapy' >Doctor of Physical Therapy<\/option><option value='Doctor of Physical Therapy- Northwest' >Doctor of Physical Therapy- Northwest<\/option><option value='Doctor of Podiatric Medicine' >Doctor of Podiatric Medicine<\/option><option value='Doctor of Veterinary Medicine' >Doctor of Veterinary Medicine<\/option><option value='Masters of Science in Health Sciences' >Masters of Science in Health Sciences<\/option><option value='Masters of Science in Medical Sciences' >Masters of Science in Medical Sciences<\/option><option value='Masters of Science in Biotechnology and Pharmaceutical Sciences' >Masters of Science in Biotechnology and Pharmaceutical Sciences<\/option><option value='Masters of Science in Physician Assistant Studies' >Masters of Science in Physician Assistant Studies<\/option><option value='Nursing - All programs' >Nursing - All programs<\/option><option value='PhD of Science in Biotechnology and Pharmaceutical Sciences' >PhD of Science in Biotechnology and Pharmaceutical Sciences<\/option><\/select><\/div><\/li><li id=\"field_71_44\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_71_44'>Activity<\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_71_44' class='medium gfield_select'     aria-invalid=\"false\" ><option value='OREGON' >OREGON<\/option><\/select><\/div><\/li><li id=\"field_71_10\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_71_10'>Year of Graduation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_71_10' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select One' selected='selected'>Select One<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><\/select><\/div><\/li><li id=\"field_71_7\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_71_7'>WesternU E-mail Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_71_7'>MUST BE WesternU E-MAIL - DO NOT ENTER A PERSONAL E-MAIL ADDRESS HERE.<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_71_7' type='email' value='' class='medium'   placeholder='@westernu.edu' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_71_7\" \/>\n                        <\/div><\/li><li id=\"field_71_62\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>Please enter your WesternU email address. Entering your personal email address will not allow you to continue form submission.<\/p><\/li><li id=\"field_71_39\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Who is your membership with?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_71_47'>As a reminder, we Do Not\u00a0reimburse for SamFit memberships as we are contracted with them and students who join through WesternU receive a subsidized memberships.\u00a0<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_71_47'>\n\t\t\t<li class='gchoice gchoice_71_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='24 Hour Fitness'  id='choice_71_47_0'    \/>\n\t\t\t\t<label for='choice_71_47_0' id='label_71_47_0' class='gform-field-label gform-field-label--type-inline'>24 Hour Fitness<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='Anytime Fitness'  id='choice_71_47_1'    \/>\n\t\t\t\t<label for='choice_71_47_1' id='label_71_47_1' class='gform-field-label gform-field-label--type-inline'>Anytime Fitness<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_2'>\n\t\t\t\t<input name='input_47' type='radio' value='Astoria Full Fitness'  id='choice_71_47_2'    \/>\n\t\t\t\t<label for='choice_71_47_2' id='label_71_47_2' class='gform-field-label gform-field-label--type-inline'>Astoria Full Fitness<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_3'>\n\t\t\t\t<input name='input_47' type='radio' value='Chuze'  id='choice_71_47_3'    \/>\n\t\t\t\t<label for='choice_71_47_3' id='label_71_47_3' class='gform-field-label gform-field-label--type-inline'>Chuze<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_4'>\n\t\t\t\t<input name='input_47' type='radio' value='Crunch'  id='choice_71_47_4'    \/>\n\t\t\t\t<label for='choice_71_47_4' id='label_71_47_4' class='gform-field-label gform-field-label--type-inline'>Crunch<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_5'>\n\t\t\t\t<input name='input_47' type='radio' value='Esporta Fitness'  id='choice_71_47_5'    \/>\n\t\t\t\t<label for='choice_71_47_5' id='label_71_47_5' class='gform-field-label gform-field-label--type-inline'>Esporta Fitness<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_6'>\n\t\t\t\t<input name='input_47' type='radio' value='Fitness 19'  id='choice_71_47_6'    \/>\n\t\t\t\t<label for='choice_71_47_6' id='label_71_47_6' class='gform-field-label gform-field-label--type-inline'>Fitness 19<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_7'>\n\t\t\t\t<input name='input_47' type='radio' value='Hangar 18'  id='choice_71_47_7'    \/>\n\t\t\t\t<label for='choice_71_47_7' id='label_71_47_7' class='gform-field-label gform-field-label--type-inline'>Hangar 18<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_8'>\n\t\t\t\t<input name='input_47' type='radio' value='LA Fitness'  id='choice_71_47_8'    \/>\n\t\t\t\t<label for='choice_71_47_8' id='label_71_47_8' class='gform-field-label gform-field-label--type-inline'>LA Fitness<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_9'>\n\t\t\t\t<input name='input_47' type='radio' value='Lebanon Racquetball and Fitness'  id='choice_71_47_9'    \/>\n\t\t\t\t<label for='choice_71_47_9' id='label_71_47_9' class='gform-field-label gform-field-label--type-inline'>Lebanon Racquetball and Fitness<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_10'>\n\t\t\t\t<input name='input_47' type='radio' value='Online only gym'  id='choice_71_47_10'    \/>\n\t\t\t\t<label for='choice_71_47_10' id='label_71_47_10' class='gform-field-label gform-field-label--type-inline'>Online only gym<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_11'>\n\t\t\t\t<input name='input_47' type='radio' value='One Pass Select (Optum)'  id='choice_71_47_11'    \/>\n\t\t\t\t<label for='choice_71_47_11' id='label_71_47_11' class='gform-field-label gform-field-label--type-inline'>One Pass Select (Optum)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_12'>\n\t\t\t\t<input name='input_47' type='radio' value='Planet Fitness'  id='choice_71_47_12'    \/>\n\t\t\t\t<label for='choice_71_47_12' id='label_71_47_12' class='gform-field-label gform-field-label--type-inline'>Planet Fitness<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_13'>\n\t\t\t\t<input name='input_47' type='radio' value='YMCA'  id='choice_71_47_13'    \/>\n\t\t\t\t<label for='choice_71_47_13' id='label_71_47_13' class='gform-field-label gform-field-label--type-inline'>YMCA<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_47_14'>\n\t\t\t\t<input name='input_47' type='radio' value='gf_other_choice'  id='choice_71_47_14'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_71_47_other' name='input_47_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_71_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_35\" class=\"gfield gfield--type-number gfield--input-type-number gf_left_half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_71_35'>Enter amount to be reimbursed.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_71_35'>For example, if your renewal fee was $99, enter $99 below. If you paid $350 total for your one year memberships then enter $100 below.<\/div><div class='ginput_container ginput_container_number'><input name='input_35' id='input_71_35' type='text' step='any' min='1' max='100' value='' class='medium'    placeholder='May not exceed $100 OR the total amount you paid.' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_71_35 gfield_description_71_35\" \/><div class='gfield_description instruction ' id='gfield_instruction_71_35'>Please enter a number from <strong>1<\/strong> to <strong>100<\/strong>.<\/div><\/div><\/li><li id=\"field_71_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >All payments are processed via direct deposit unless you are not set up with the Bursar&#039;s Office.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_71_32'>\n\t\t\t<li class='gchoice gchoice_71_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='I am set up for direct deposit'  id='choice_71_32_0'    \/>\n\t\t\t\t<label for='choice_71_32_0' id='label_71_32_0' class='gform-field-label gform-field-label--type-inline'>I am set up for direct deposit<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='I am not set up for direct depost and would like a check'  id='choice_71_32_1'    \/>\n\t\t\t\t<label for='choice_71_32_1' id='label_71_32_1' class='gform-field-label gform-field-label--type-inline'>I am not set up for direct depost and would like a check<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_71_40\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >How do you pay for your membership?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_71_4'>\n\t\t\t<li class='gchoice gchoice_71_4_0'>\n\t\t\t\t<input name='input_4' type='radio' value='Monthly'  id='choice_71_4_0'    \/>\n\t\t\t\t<label for='choice_71_4_0' id='label_71_4_0' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_71_4_1'>\n\t\t\t\t<input name='input_4' type='radio' value='Annually'  id='choice_71_4_1'    \/>\n\t\t\t\t<label for='choice_71_4_1' id='label_71_4_1' class='gform-field-label gform-field-label--type-inline'>Annually<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_71_53\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br \/>\n<br \/><\/li><li id=\"field_71_49\" class=\"gfield gfield--type-html gfield--input-type-html gf_right_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><b>Regardless of how you pay you must have proof of:<\/b><\/br>\n1) Payment during the current academic year.<br \/>\n2) Membership dates.<br \/>\n3) That the membership is in your name.<br \/>\n<\/br>\n\n,\/br>Please note that regardless of how you pay, your membership must be active (with proof of payment) for at least 10-months during the current academic year. Specifically, this includes an active membership for following periods: July-April, August-May, or September-June.\n<\/li><li id=\"field_71_56\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br \/><\/li><li id=\"field_71_42\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Proof of Membership\/Payment<\/h2><\/li><li id=\"field_71_59\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_71_59'>What date did your membership begin:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_59' id='input_71_59' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_71_59_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_71_59_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_71_59' class='gform_hidden' value='https:\/\/forms.westernu.edu\/students\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_71_60\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_71_60'>What date is your current membership ending:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_60' id='input_71_60' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_71_60_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_71_60_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_71_60' class='gform_hidden' value='https:\/\/forms.westernu.edu\/students\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_71_82\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_81\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Please do not submit 10-months of your full credit card statements as it's too cumbersome and shares personal data that we don't need. The best option is to get a billing statement from your gym(s).  If credit card statements are your only option, then black out all other purchase and the account number. <\/li><li id=\"field_71_13\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_71_13'>Upload Proof:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_71_13'>PLEASE MERGE YOUR DOCUMENTS INTO ONE PDF BEFORE UPLOADING<br \/>\n<br \/>\n<b>1) Of membership dates.<\/b><br \/>\nMust have proof of membership for a minimum of 10 months within the current academic year: July-June<br \/>\n<b>2) Of payment<\/b><br \/>\nMust show that the membership is paid in full (for annual) or proof of payment for ALL 10 months (if month-to-month).<br \/>\nIf providing your credit card statement you must block out personal information and purchases not needed for this request. <br \/>\n<b>3) That the membership is in your name<\/b><br \/>\nThis is a benefit for current students only<br \/>\n<b>\n<\/b>\n<br \/><br \/>\nSend questions to studentaffairs@westernu.edu<\/div><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_71_13' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_71_13&quot;,&quot;container&quot;:&quot;gform_multifile_upload_71_13&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_71_13&quot;,&quot;filelist&quot;:&quot;gform_preview_71_13&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/forms.westernu.edu\\\/students\\\/?gf_page=d5bc9addb501f57&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/forms.westernu.edu\\\/students\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/forms.westernu.edu\\\/students\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;pdf&quot;}],&quot;max_file_size&quot;:&quot;131072000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:71,&quot;field_id&quot;:13,&quot;_gform_file_upload_nonce_71_13&quot;:&quot;626fad0079&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;1&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_71_13&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_71_13' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_71_13' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_71_13 gfield_description_71_13\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_71_13'>Accepted file types: pdf, Max. file size: 125 MB, Max. files: 1.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_71_13'><\/ul> <div id='gform_preview_71_13' class='ginput_preview_list'><\/div><\/div><\/li><li id=\"field_71_43\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_83\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br>\n<br><\/li><li id=\"field_71_63\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  >The submit button is hidden because you indicated you pay MONTHLY for your membership. At this time, we are only accepting ANNUAL PREPAID requests.  If you pay monthly for your membership please wait until you've paid for 10 CONSECUTIVE MONTHS (specifically, this includes an active membership for following periods: July-April, August-May, and September-June) and then submit your request. The deadline for the 2025-2026 AY is June 1, 2026.<\/li><li id=\"field_71_84\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >The submit button is hidden because you indicated you pay ANNUALLY for your membership. At this time, we are only accepting MONTHLY PAID requests.  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