This form contains FOR OFFICIAL USE ONLY information which must be protected under the Freedom of Information Act (5 U.S.C. 552) and/or the
Privacy Act of 1974 (5 U.S.C. 552a). Unauthorized disclosure or misuse of PERSONAL INFORMATION may result in disciplinary action, criminal
and/or civil penalties. Further distribution is prohibited without the approval of the author unless the recipient has a need to know in the
performance of official duties. If you have received this in error, please notify the sender and delete all copies.
06/18/2020 - 14
INSTRUCTIONS: See “Program Instructions and Requirements for additional information.
COMMAND USE ONLY: (1) to certify a NEW Independent Duty Station (IDS); (2) to designate a new or change the
existing YMCA and/or Private Fitness to be used by all personnel and dependents assigned to the IDS; (3) to request an
exception for additional facilities to support the IDS. Please do not submit this form with each membership application.
Maximum of one YMCA and one private fitness facility per IDS. If facility provides local or nationwide access at no
additional cost to the government, members may use participating locations; however, for liability and contract
payment purposes, members must list the unit-designated facility name and address on their application form.
Exceptions for additional fitness facilities to support a single IDS location will be considered on a case-by-case basis
and require strong justification. Submit request on Service letterhead signed by the Command/Office in Charge
with a copy of this form completed for EACH additional facility required.
Email completed form to appropriate Military Component Approving Official (MCAO) org box
Section 1
Status (Select ALL that apply): Establish New IDS Designate Facility Exception Request (memo atch.)
Command Name: _______________________________________________________________________________
CMD Address: __________________________________________________________________________________
CMD POC: ___________________________________________ CMD POC Phone: ___________________________
CMD POC Duty Email: ____________________________________________________________________________
IDS Unit Name: ________________________________________________ IDS Phone: _______________________
IDS Physical Address: _____________________________________________________________________________
Section 2
Facility Designation (Select One): New IDS Facility Change Designated Facility Request Exception Facility
YMCA Name: ____________________________________________________________________________________
Street Address: _________________________________________________________________________________
Private Fitness Name: ____________________________________________________________________________
Street Address:
Commanding Officer/Officer in Charge:
I certify the specified physical address is an establish Independent Duty Station (IDS) and that
the command/unit does not pay for fitness memberships or have access to a free or Service-provided fitness facility at or near the IDS. I
understand that all assigned personnel choosing to participate must use a unit-designated facility, must comply with the mandatory attendance
to be eligible for renewal, and they must accept personal responsibility for payment of any excess monthly membership fee if the designated
facility exceeds the government contract rate cap ($50 single / $70 family).
Digital Signature: _______________________________________________ Duty Title: ______________________
Duty Email: _______________________________________________ Duty Phone: __________________________
MCAO Verification: IDS Registered Facility count within limit (1/1)
igital Signature/Date:____________________________________________________________________________
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