Single Member Sign-Up - Fit Physique

Name *

First

Last

Date of Birth *

Are you over 18? If you are not, you must sign-up in-person. *

Full Address *

Cell Phone Number *

Cell Phone Carrier/Provider *

Email *

Emergency Contact *

First

Last

Their Cell Phone Number *

List your medical history *

___High Blood Pressure ___Chest Pain ___Orthopedic Conditions ___Stroke ___Heart Disease ___Heart Attack ___Dizziness/Vertigo ___Osteoporosis ___Hypoglycemia ___Diabetes ___Heart Murmur ___Hernia ___Anemia ___High Cholesterol ___Shortness of Breath ___Arthritis ___Cancer ___Irregular Heart Rate ___Respiratory Disease ___Thyroid Disorder ___Blood Disorder ___Epilepsy or Convulsions ___Gastrointestinal Disorder ___Depression ___Pacemaker ___Electrical Implant ___High Stress ___ Abnormal Heart Rhythm ___Varicose Veins ___Lung Disease ___Rheumatic ___Insomnia ___Loss of Consciousness

Fitness Goals *

Release of Liability & Assumption of Risk *

Agree

As a 24-hour secure-access fitness facility, Fit Physique LLC (hereafter referred to as "the gym"), has a few different policies and procedures than a typical fitness facility. Please read the information carefully. If you have any questions, please ask. Acknowledgement of Risk and Waiver of Liability I voluntarily assume the risk of injury, accident, death, loss, cost or damage to my person or property which might arise from my use of the gym, and I agree to hold harmless and release the gym and all affiliated corporations, and its officers, directors, board members, agents, employees, representatives, executors, and all others from any and all liability. I also release all of those mentioned and any others acting on their behalf from any responsibility or liability for any injury or damage to myself including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities or the use of any equipment at the gym during staffed or non-staffed hours. General Statement of Program Objectives and Procedures I understand that a physical fitness program may include exercises to build the cardiorespiratory system (heart and lungs), the musculoskeletal system (muscle endurance, strength and flexibility), and to improve body composition (decrease of body fat in individuals needing to lose fat, with an increase in muscle and bone). Exercise may include aerobic activities (treadmill walking/running, bicycle riding, rowing machine exercise, group aerobic activity, swimming, and other such activities), calisthenics, and weight lifting to improve muscular strength and endurance, and flexibility exercises to improve joint range of motion. Description of Potential Risks I understand that the reaction of the heart, lung, and blood vessel system to such exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during or during exercise, which may include abnormalities of blood pressure or heart rate, in effect of functioning of the heart, and in rare instances heart attacks. Use of the weight lifting equipment, and engaging in heavy body calisthenics, can lead to musculoskeletal strains, pain, and injury if adequate warm-up, gradual progression, and safety procedures are not followed. (PAR-Q) Physical Activity Readiness Questionnaire Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Becoming more active is very safe for most people. However, some people should check with their Doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, this questionnaire (the PARQ) will tell you if you should check with your Doctor before you start. If you are over 69 years of age and you are not used to being active, check with your Doctor. Cleared for Exercise I certify that I am in good physical health and I am able to undertake and engage in the range of physical activities in which I choose to participate at the gym. I assume all responsibility for updating the facility with respect to any changes in my physical or mental condition and for reporting all injuries sustained at the facility to the gym staff. I understand and am aware that strength, flexibility, aerobic and anaerobic exercise, including the use of any equipment, is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury and even death and that I am voluntarily participating in these activities and using equipment with knowledge of all the dangers involved. I do hereby agree to expressly assume and accept any and all risks of injury or death either accidental or otherwise. This waiver, release and indemnification agreement includes, without limitation, all injuries which may occur as a result of (a) my use of all amenities and equipment in the facility and my participation in any class, activity or personal training, (b) sudden unforeseen malfunctioning of any equipment and (c) my slipping or falling while in the facility, on the facility premises, including adjacent sidewalks and parking areas. I acknowledge that I have carefully read this waiver, release and indemnification agreement and fully understand that it is a full and complete release of all liability. Duty to Inform of Changes in Health Condition I understand that I am required to inform the gym of any material changes in my health condition in the future, including but not limited to, any changes which would cause me to change my responses to the PARQ above. General This contract represents the complete understanding between you and the gym. No representations, written or oral, other than those contained in this contract are authorized or binding upon the gym. Should any part of this agreement due to legal or other regulatory changes become unenforceable, the remaining provisions within this agreement not impacted by such change shall remain in full force as originally written. You agree to promptly update the gym of any changes of address, phone, e-mail address and/or bank account/credit card information. Other No use of tanning beds, spa area, personal training room, or back room during non-staffed hours. Unauthorized areas are clearly marked and secured with motion sensors and cameras during non-staffed hours. Please do not access these areas.

Initial your acceptance and understanding of all the above subjects. *

Initial your acceptance and understanding. *

WAIVER AND RELEASE AGREEMENT Please read carefully before signing This is a release of liability and waiver of certain legal rights (Type "Fit Physique") *

As additional consideration for allowing both my participation in an exercise training program or instruction and use of its facilities, I agree to the following Waiver and Release: I acknowledge that participation in an any exercise training program, including but not limited to weight lifting, running, jumping, balance, nutrition counseling, and sports performance training has certain inherent risks, hazards, and dangers which cannot be completely eliminated despite all safety precautions, including the potential for severe injury, paralysis, or death. I AM VOLUNTARILY PARTICIPATING IN AN EXERCISE TRAINING PROGRAM(S) AND INSTRUCTION WITH FULL KNOWLEDGE OF THE INHERENT RISKS, HAZARDS, AND DANGERS INVOLVED AND HEREBY ASSUME AND ACCEPT ANY AND ALL RISKS OF INJRY OR DEATH. I, for myself, my heirs, successors, executors, and assigns, hereby KNOWINGLY AND INTENTIONALLY WAIVE, RELEASE, AND HOLD HARMLESS its members, directors, officers, agents, employees, instructors, coaches and volunteers from and against any and all claims, actions, causes of action, liabilities, suits, expenses (including reasonable attorney’s fees) arising directly or indirectly from my participation in any exercise training program or instruction or arising while I am under the instruction, supervision, and/or control of any of the released parties, regardless of whether the damage, loss, injury, paralysis, or death results from negligence of any released party or from some other cause.

I HAVE CAREFULLY READ, CLEARLY UNDERSTAND, AND VOLUNTARILY SIGN THIS WAIVER AND RELEASE AGREEMENT. You must be at least 18 years old to sign, otherwise the signature of a parent or legal guardian is required: *

Type your full name above.

Today's Date *

Fit Physique Gym Membership Contract Fit Physique LLC will run an auto renew EFT membership. In short your account will be debited the membership rate indefinitely on a month to month basis until cancellation is qualified and obtained. DO NOT SIGN UNTIL READ. *

Student and Family Memberships must be completed in-person.

will be withdrawn on the (type today's date) *

EFT Request and Authorization: Client hereby authorizes Fit Physique LLC or its assigns to make periodic charges or withdrawals (“EFT Authorization”) from the account used to pay the initial payment described above or the account listed below or replacement account designated by Client and accepted by Fit Physique LLC for payment of any and all fees, late charges, costs, expenses, or any other monies (see “Weight & Cardio Room Rules and Guidelines to Follow” page) due to Fit Physique LLC under the terms and conditions of this Agreement. Client understands that Client is entitled to notice of all varying charges and withdrawals under the EFT, but Client waives the right to receive prior notice for charges or withdrawals made with respect to any uncollected payments or portions of the balance due described above and the corresponding service charges, both of which Client agrees are not varying charges or withdrawals. Client may timely notify the financial institution in control of Client’s account to terminate this Request, but such notification will constitute a default and may cause all sums under this Agreement to be due and payable immediately together with all costs of collection to extent permitted by law. Fit Physique LLC or its assigns reserves the right to add the following fees to the Client’s account balance should any of the following occur.

Failed authorization of credit card debit – fifteen dollars ($15.00) *

Agree

Note: Memberships are non-refundable or transferable. No exceptions. PAYMENT AND BILLING: Client has two options for payment: (1) Payment in full may be made for all services (year membership), or (2) Monthly payment by credit card per the guidelines of the Agreement. The date the Agreement is signed shall be the billing date for the Client. Each month on this date, the monthly payment is charged to the Client’s credit card. Should Client’s credit card payment fail to authorize for any reason, a $10 late fee will apply if Client fails to provide a valid credit card within 10 calendar days of the original rejection date.

I understand

CANCELLATION I have been told that my contract does not end automatically and that it will continue on indefinitely on a month to month basis until I cancel it by following the below procedures. If I qualify based on one of the reasons listed below, I am aware that I must do the following things in order to cancel my membership: 1. Must come in to facility to cancel in person. 2. Cancellation must be made at least 7 days before your next billing cycle date. No exceptions. We do not pro rate the last payment. No exceptions. *

I understand

TO QUALIFY FOR CANCELLATION By Fulfilling the Contractual Obligation – You may cancel a membership once the entire contractual obligation has been met by requesting a cancellation in writing only by completing a cancellation request form at the gym. Please note, due to needing an original signature our company does not accept faxes or emails. Pro rates are not full payments and are not counted as so. Per the contract the account must be current in order to submit a cancellation request. Also, our billing service requires a 7 day notice and that the last payment be paid at the time of the request. The 7 days is not prorated but means you must make a full payment if one falls within 7 days of when the request was made or received.

Do not sign unless you have fully read this form and agree to all of it terms! Cancellation will be denied should the last 30-day payment be returned. If the payment is denied or returned for any reason I am aware that I must resubmit a new cancellation request by starting over. I am also aware that I will be subject to any and all fees associated with the denial (NSF or Chargeback fees) and that I will be subject to another 30-day monthly payment. I am aware that I am solely responsible for understanding the process for canceling my membership as stated above. I understand that I cannot contact an employee by phone to request a cancellation or for information regarding cancellation. I will take full responsibility for my cancellation and will not blame an employee for not following the above protocol. I promise to follow the policies numbered above when it comes time for me to cancel. I also promise that I will accept full responsibility for knowing the procedures and will not blame an employee should I fail to follow them since this form clearly explains the process. *

I understand

24-hour gym members are subject to a ONE-TIME ACCESS KEY FEE OF $10.00 ALL lost, stolen, or broken keys will require a re-activation fee of $10.00. Check to confirm your acceptance. *

I understand

Compliance with Rules I understand and agree that a 24-hour gym membership is a special membership based on trust and is a privilege, which can be taken away for a violation of rules. As a gym member, I agree to abide by all gym membership rules and 24-hour membership rules, which will be posted at the facility, web-site and may be amended from time to time at the sole discretion of the gym. The additional rules below apply to a 24-hour membership: *

I understand

• Only one 24-hour member may enter the gym front door at a time • Access card sharing is strictly prohibited and will result in immediate loss of membership. Card Sharing is viewed by ownership as stealing services• Violations will be reported to law enforcement for criminal prosecution • Using your access code when membership fees are due will be viewed as stealing and will result in immediate loss of membership. • Only active account members will be allowed entry • Pre-approved 24 hour members under the age of 18 must be accompanied by an approved member parent until they reach the age of 18. Check to agree to agree. *

I understand

I agree that improper unauthorized use of the facility may result in member suspension or cancellation. I agree not to let anyone use my access card for any reason, and I agree to report any situation that appears to be access card sharing to the gym staff. A security *

I understand

No Supervision. I understand that I am purchasing a membership at a 24-hour facility that allows access at any time. As such, I am aware that there will be no supervision or assistance except during staffed hours. Staffed hours may change at the sole discretion of the gym. I am aware that if I get injured, become unconscious, suffer a stroke or heart attack or any other medical emergency or event that there will likely be no one to respond to my emergency and that the gym has no duty to provide assistance to me while I am at the gym. I understand that even though the gym is equipped with surveillance cameras, these record but are not monitored continuously, help will not be available during non-staffed hours. *

I understand

Please complete the card information below, which hereby authorizes FIT PHYSIQUE LLC to debit the following card for the above membership each month. *

Name on the card

Credit Card Number *

Carefully enter

Credit Card Expiration Date (XX/XX) *

Carefully enter

Credit Card CVV *

Carefully enter

Zipcode *

Signature to Authorize Card *

By entering my full name above I am agreeing to/electronically signing to the terms discussed above.

Today's Date *

I certify that I have read and understand all of the terms of the gym agreement and agree to continue to abide by all of the terms of this agreement. *

I understand.

By entering my full name above I am agreeing to/electronically signing to the terms discussed above.

Access Card Retrieval: (1) Upon successful completion of this membership form & (2) successful authorization of your credit card submitted; (3) 24/7 Access Card(s) will need to picked up on site during staff hours. Thank you! :] *

Sounds good, I will stop-in!