Fill and Sign the Personal Training or Trainer and Fitness Center Membership Application and Agreement Including Waiver and Indemnification Form

Personal Training and Fitness Center Membership Application and Agreement including Waiver and Indemnification Agreement __________________________ ________________________ __________ Last Name First Name Middle Initial _______________________________ _________________ ___________ _________ Street Address City State Zip Birth date: __________ Home Phone: _____________ Work Phone: _________ Cell: _____________ Name of Emergency Contact: _____________________________________________  Home Phone: _____________ Work Phone: _______________ Cell: _____________  Relationship of Emergency Contact: ____________________________________  Email of Emergency Contact: ____________________________ Check type of Membership desired: [ ] MONTHLY MEMBERSHIP: I understand and agree that my monthly membership dues of $________________ , will be automatically drafted from my credit card or bank account each month on the ____________ (day of month) or ________ (day of month) (circle one) beginning __________________ (date) for a minimum of ______ months. My automatic payment plan will automatically renew and continue until canceled by me in writing by certified mail. Cancellation takes effect ______ days from the postmark on certified letter. I agree to all membership terms and conditions as outlined below and on the Automatic Payment Account Information page (if applicable). [ ] PAID IN FULL MEMBERSHIP: Length of Time Purchased ______________ Expires ________________ Initiation Fee: $_______________ First Month’s Dues: $_______________ Registration Fee: $_________ Amt. Received Today: $_____________ [ ] Cash [ ] Check [ ] Credit Card TOTAL AMOUNT DUE __________________ Balance Remaining: $_____________ [ ] Payable by following installments AMOUNT DUE DATE PAYMENT METHOD Installment No. 1: $__________ on__________________ (date) ; [ ] Check [ ] DRAFT Installment No. 1: $__________ on __________________ (date) ; [ ] Check [ ] DRAFT Installment No. 1: $__________ on __________________ (date) ; [ ] Check [ ] DRAFT Installment No. 1: $__________ on __________________ (date) ; [ ] Check [ ] DRAFT Late Payment and Default: Should you default on any payment obligation as called for in this agreement, the entire remaining balance plus any applicable fees shall be deemed due and payable upon demand. You will be subject up to a $___________ late fee (plus any applicable tax) for any unpaid balances and returned checks, bank drafts, credit cards or debit cards due to (but not limited to) the following: NSF’s, closed accounts, stopped payments, invalid accounts, declined credit card, lost or stolen credit card, holds on credit card, invalid or wrong credit card expiration dates etc. It is your responsibility to notify your bank in writing of any change in your automatic draft payment method _____ business days prior to your draft date. Any returned or declined credit card transactions will be drafted _____ days after the initial transaction and will include late fees of $__________. We reserve the right to redraft any past dues amounts and\or service fees at any time without prior notice to you. IF YOU DECIDE YOU DO NOT WISH TO REMAIN A MEMBER OF THIS FITNESS CENTER, YOU MAY CANCEL THIS AGREEMENT BY MAILING, TO THE FITNESS CENTER BY MIDNIGHT OF THE THIRD (3) BUSINESS DAY AFTER THE DAY YOU SIGN THIS AGREEMENT, A NOTICE STATING YOUR DESIRE TO CANCEL THIS AGREEMENT. THE WRITTEN NOTICE MUST BE MAILED BY CERTIFIED MAIL TO THE FOLLOWING ADDRESS: __________________________________________________________________ (street address, city, state, zip code) . ALSO RETURN ALL AGREEMENT COPIES, TEMPORARY CARDS, AND/OR MEMBERSHIP CARD. NOTICE TO PURCHASER: 1. DO NOT SIGN THIS AGREEMENT UNTIL YOU READ IT OR IF IT CONTAINS BLANK SPACES 2. By signing this Agreement you certify that you have read, understand and agree to all pages of this Agreement. PERSONAL TRAININGTERMS and CONDITIONS Membership Information: If you have any questions regarding your membership, contact __________________________ (Name of Fitness Center) at ________________ (Phone Number) . You will be mailed a membership letter containing a copy of this Agreement along with a membership slide card. You are required to bring the slide card with you when you come to use the facility. Replacement cards are $____________. Rules and Regulations : By signing this Agreement, you acknowledge the rules and regulations governing the conduct of members and guests, and you agree to follow them. Guests: Member shall be entitled to bring a guest or guests to the Fitness Center, but only pursuant to such rules, regulations, fees, schedules and/or charges for such guest or guests as may then be in force by the Fitness Center. _________________________ (Name of Fitness Center) reserves the right to limit the number of guests or the number of times any one guest can use the Fitness Center’s facilities and reserves the all rights to exclude any guest whose use of the facilities, in the sole opinion of __________________________ (Name of Fitness Center) , would be detrimental to ____________________________ (Name of Fitness Center) or any of its Members. No guest may use the facilities without “signing in” at the front desk and no guest may use the Fitness Center or any of its facilities or activities without being accompanied at all times by the member. Services : We agree to provide you with use of our facilities and all equipment and amenities which are available to you under the terms of your particular membership. We reserve the right to add or delete services, amenities, and hours as reasonably warranted. Freezes : You have the option to freeze your membership up to ______ months at a time. Term memberships paid on a monthly basis may freeze time not payments. Memberships can be frozen for a $___________ a month fee. Initiation Fee : By paying the initiation fee, you are purchasing the privilege of membership to the facility. The initiation fee is considered fully earned upon commencement of your membership and as a result is non-refundable. Monthly Dues : Monthly dues represent the cost of having use of the facility available to you for a _______ (number) day period. Dues are considered fully earned the first day of any thirty day availability period. Funds must be available on the date of payment and after until such payment clears. You will not have use of the Fitness Center if you have an outstanding balance. Member agrees to maintain membership for the minimum length of time ____________________ (term) as stated on this Agreement. Drafting memberships automatically renew and can be cancelled only after the minimum term of Agreement has passed by following the cancellation policy in the following paragraph. Cancellation prior to the agreed upon term does not eliminate member’s obligation to continue making monthly payments as stated in this agreement (see health, disability & death exceptions). Member will be responsible for all unpaid balances as well as court costs and legal fees associated with recovering said balances. All prices are guaranteed for only the length of time stated in this agreement. Restriction on Cancellation : If you fail to use your membership and do not use our facilities, you are not relieved of your payment obligation, regardless of the circumstance, except as provided for in this Agreement. CANCELLATION POLICY: Please note all draft memberships will continue on a month to month basis until cancelled by member with a 30 day written notice . Member must send a written notice by certified (returned receipt) mail to the following address: __________________ _____________________________________________________________ (street address, city, state, zip code) . YOU MAY NOT CANCEL AT THE FACILITY. All cancels take effect ______ (number) days from the postmark on the certified letter. Your membership slide card must be returned with your cancellation. IF THE FITNESS CENTER GOES OUT OF BUSINESS AND DOES NOT PROVIDE FACILITIES WITHIN 10 MILES OF THE FACILITY IN WHICH YOU ARE ENROLLED OR IF THE FITNESS CENTER MOVES MORE THAN _________ MILES FROM THE FACILITY IN WHICH YOU ARE ENROLLED, YOU MAY CANCEL THIS AGREEMENT BY MAILING A NOTICE TO THE FITNESS CENTER STATING YOUR DESIRE TO CANCEL THIS AGREEMENT, ACCOMPANIED BY PROOF OF PAYMENT ON THE AGREEMENT. THE WRITTEN NOTICE MUST BE MAILED BY CERTIFIED MAIL TO THE FOLLOWING ADDRESS: _________________________________________________________ ________ (street address, city, state, zip code) . OUR DOCTOR DETERMINES THAT YOU ARE ILL OR INJURED TO THE EXTENT THAT IN YOUR DOCTOR’S OPINION YOU ARE UNABLE TO USE THE FACILITIES AFTER THE DATE THIS AGREEMENT TAKES EFFECT, YOU MAY CANCEL THIS AGREEMENT AND RECEIVE A PARTIAL REFUND OF YOUR UNUSED MEMBERSHIP FEE BY MAILING A NOTICE TO THE FITNESS CENTER STATING YOUR DESIRE TO CANCEL THIS AGREEMENT. THE FITNESS CENTER MAY REQUIRE PROOF OF ILLNESS OR INJURY. THE WRITTEN NOTICE MUST BE MAIL BY CERTIFIED RETURN RECEIPT MAIL TO THE FOLLOWING ADDRESS: __________________________________ ___________________________________________ (street address, city, state, zip code) . Relocation : You may cancel a term Agreement if you relocate more than _______ driving miles from the facility at which you enrolled or from an affiliated facility. You must give a written notice of your intention to cancel, satisfactory evidence of relocation such as a utility bill, a $_________ cancellation fee and you must not carry a past due balance. This must be sent in by certified return receipt mail to the following address: ________________________________ __________________________________________________ (street address, city, state, zip code) . YOU MAY NOT CANCEL AT THE FACILITY. Assignment of Agreement : We reserve full authority to sell, assign or transfer our right to receive payment from you at our discretion. If for any reason a member is unable to use their membership, the member may transfer the remaining time to another person for a $__________ fee. WE DO NOT GIVE REFUNDS. Severability: The invalidity of any portion of this Agreement will not and shall not be deemed to affect the validity of any other provision. If any provision of this Agreement is held to be invalid, the parties agree that the remaining provisions shall be deemed to be in full force and effect as if they had been executed by both parties subsequent to the expungement of the invalid provision. No Waiver: The failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. Governing Law: This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of _____________. Notices: Unless provided herein to the contrary, any notice provided for or concerning this Agreement shall be in writing and shall be deemed sufficiently given when sent by certified or registered mail if sent to the respective address of each party as set forth at the beginning of this Agreement. Mandatory Arbitration: Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. Entire Agreement: This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement. Modification of Agreement: Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if placed in writing and signed by each party or an authorized representative of each party. Assignment of Rights: The rights of each party under this Agreement are personal to that party and may not be assigned or transferred to any other person, firm, corporation, or other entity without the prior, express, and written consent of the other party. Compliance with Laws: In performing under this Agreement, all applicable governmental laws, regulations, orders, and other rules of duly-constituted authority will be followed and complied with in all respects by both parties. In this Agreement, any reference to a party includes that party's heirs, executors, administrators, successors and assigns, singular includes plural and masculine includes feminine. PERSONAL TRAINING AUTOMATIC PAYMENT ACCOUNT INFORMATION I understand and agree to use the account information below for my membership dues as outlined above. Membership Agreement #: _________ Print Members Name : __________________________ Member’s Signature: ___________________________ Date: ________________________ Printed Name of Member: _________________________________________ BANK DRAFT (Attach voided check here): (Attached Check) CREDIT CARD DRAFT (Attach voided credit card slip here): (Voided credit card slip) SCREENING AND RELEASES Evolve Personal Training is not a medical organization and its staff cannot provide medical advice. You are advised to consult with your physician prior to beginning this exercise program and encouraged to seek periodic medical check-ups. If you are under the care of a physician, taking prescription medication, or following a diet to treat an illness or disease, you should discuss this exercise program with your physician. Medical Information (check any that apply) [ ] Overweight [ ] Pregnant [ ] Poor posture [ ] Hypoglycemia [ ] Arthritis/Bursitis [ ] Drug allergies [ ] Bad back [ ] Hernia [ ] Sports injury [ ] Problem knees [ ] Sleep problems [ ] Recent Surgery [ ] Fatigue/Drowsiness [ ] Asthma [ ] Nervous Tension [ ] Headaches [ ] Physical activity [ ] Lightheadedness/Fainting [ ] Staff should know: _____________________________________________________ Major Coronary Risk Factors: (check any that apply) [ ] Diagnosed with hypertension [ ] High cholesterol (>200mg/DL) [ ] Diabetes Mellitus Type I [ ] Family history of coronary disease [ ] Cigarette smoker [ ] Phlebitis Embolic [ ] Diabetes Mellitus Type II [ ] Other heart conditions: [ ] High Blood Pressure Do you take a Beta Blocker? [ ] Yes [ ] No Are you taking medication/supplements to help with weight loss? [ ] Yes [ ] No What are your goals? (check all that apply) [ ] Lose inches [ ] Better flexibility [ ] Shape and tone [ ] Be healthier [ ] Better posture [ ] More energy [ ] Other (specify) _______________________________________________ The above screening has been reviewed prior to engaging in any physical activities. What time will you most often work out? [ ] Morning [ ] Afternoon [ ] Evening Which days of the week will you most often work out? [ ] Mon. [ ] Tue. [ ] Wed. [ ] Thur. [ ] Fri. [ ] Sat. Waiver and Release I do hereby further declare myself to be physically sound and suffering from no condition, impairment, or other illness that would prevent my participation or use of the facilities and equipment. I do further hereby acknowledge that I have been informed of the need for a Physicians approval for my participation in exercise/fitness/weight loss activities, or use of equipment. I acknowledge that I have either had a physical examination and have been given my Physician’s permission to participate, OR that I have decided to participate in activities, use equipment and weight loss without the approval of a Physician and do hereby assume all responsibilities. . I, the member or participant understand and agree that fitness activities including weight loss may be strenuous and/or hazardous activities and I should contact a healthcare professional or doctor before beginning any new activities or weight loss program. I am voluntarily participating in these activities and using the facilities and equipment of with full knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death related hereto. In consideration of being allowed to participate in the activities and programs of ____________________________ (Name of Fitness Center) , use of its facilities and equipment, and in the addition to any payment of any fees or charges, I do hereby waive, release and forever discharge _________________________ (Name of Fitness Center) , its officers, agents, employees, representatives, executors, and all others from all responsibilities or liabilities for any injuries or damage resulting from my membership or participation in any activities. I also hereby release all of the above and any others acting in their behalf from any responsibility or liability for any injury of damage to myself or my belongings, including those caused by negligent act or omission, in connection with participation/membership or use of equipment at _______________________ (Name of Fitness Center) . INDEMNIFICATION Member and all heirs, representatives or assigns hereby agree to indemnify, defend and hold harmless _________________________ (Name of Fitness Center) and its officers, employees, agents, successors or assigns from any and all claims for liability against without limitation, including any interest, penalties, attorney fees and expense incurred either directly or indirectly by reason of, resulting from, or associated with this Agreement and/or _________________________ (Name of Fitness Center) . Witness my signature this _________________ (date) . ____________________________ (Printed Name of Member) ____________________________ (Signature of Member) ____________________________ (Printed Name of Witness) ____________________________ (Signature of Witness) PARENT OR GUARDIAN IF MEMBER IS UNDER AGE 18: _______________________________ Date: ________________ (Printed Name of Parent or Guardian) _______________________________ (Signature of Parent or Guardian) ______________________________ (Name of Fitness Center) By __________________________________ Date: _________________ (Printed Name and Title) ____________________________ (Signature)