Healthcare Health Club Application

Healthcare Health Club Application

Applicant Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency & Medical Contacts

Insurance Information

Medical History

Please list current medications, including dosage and frequency. Accurate medication disclosure is required for safe participation.

List allergies (medications, food, environmental) and typical reaction.

Prior surgeries or hospitalizations (include year and reason).

Chronic conditions (e.g., diabetes, asthma, arthritis). If none, enter "None".

Please indicate if you have any of the following (check all that apply):

Heart disease or prior myocardial infarction
High blood pressure
Prior stroke or transient ischemic attack
Diabetes
Unexplained chest pain or fainting
Pacemaker or implanted device
Bone/joint problems that may be aggravated by exercise
Currently pregnant

Do you currently smoke?

Yes No

If any medical conditions have been indicated above, physician clearance may be required prior to participation. Physician contact for clearance (if required):

Membership Details

Select desired membership plan:

Monthly
Annual
Family
Other:

Requested membership start date:

Preferred payment method:

Credit/Debit Card
Bank Draft
Check
Other:

Consent to Treatment; Release and Waiver

I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that participation in exercise, fitness classes, and use of health club equipment involves inherent risks, including but not limited to cardiac events, musculoskeletal injury, and other physical injury. I voluntarily assume all such risks.

In consideration of being permitted to participate in activities at the health club, I hereby release, waive and discharge the health club, its owners, operators, employees, contractors, agents and affiliates from liability for any injury, loss or damage to person or property, except to the extent caused by the health club's gross negligence or willful misconduct. I agree to indemnify and hold harmless the health club from any claims arising from my participation.

I authorize the health club and its agents to obtain emergency medical treatment for me if necessary, and I agree to be financially responsible for any medical services obtained on my behalf.

I will notify the health club in writing of any changes in my medical condition that may affect my ability to participate safely. I understand that the health club may require physician clearance prior to my participation when medically indicated.

Acknowledgement of risks and release: I have read, understand, and accept the foregoing statements and release.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the health club's privacy practices notice describing how my protected health information may be used and disclosed in connection with fitness assessments, treatment notes, billing, and member communications. I understand my rights regarding access, amendment, and restriction requests.

I acknowledge the privacy practices notice.

Communication preferences: Opt in for text messages    Opt in for emails

Authorization to Use/Release Medical Information

I authorize the release of my relevant medical information to the health club, and its agents, for the purpose of treatment coordination, emergency care, and billing as necessary for membership services. This authorization may include diagnosis, treatment history, and medication information.

Authorization expiration date:

Photograph and Media Release (Optional)

I grant permission for the health club to use photographs or video in which I may appear for internal promotion, educational, or membership materials, unless I opt out below.

I do NOT authorize use of my image

Certification

By signing below I certify that I am at least 18 years of age, or if signing on behalf of a minor, that I am the legal guardian and have the authority to execute this application and consent on the minor's behalf. I certify that all information provided is complete and accurate. I understand that falsification of medical or personal information may result in termination of membership.

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