Salem Fitness Center Application

Salem Fitness Center

MEMBERSHIP APPLICATION

Name ______________________________________ Date of Birth ______________ Age____________

Address ____________________________________ Home Phone ______________________________________

Work Phone _________________________________ Emergency Contact Phone _____________________________

Email address ________________________________

Physician ___________________________________ Physician Phone Number ____________________

CONSENT AND RELEASE:

The Salem Fitness Center will give you general health education information to help you in making informed decisions about healthcare and to help you in consulting with your physician or other health care providers. You acknowledge and agree that this program does not provide, and is not intended as a replacement for professional medical evaluation, advice, diagnosis or treatment. The Salem Fitness Center Program recommends that you consult with your physician or other healthcare provider for those services. You further acknowledge that program material you are given is dependent upon your submission of accurate, current, and complete health and lifestyle information. If the health and lifestyle information is not accurate, current or complete, then you understand that the material may not be accurate or complete.

PRIVACY STATEMENT:

The Salem Fitness Center Program treats personally identifiable information as confidential. This includes name, address, and any health information about you. With the exception of your physician, we will not share any identifiable information with anyone, unless authorized to do so by you. We may use and share aggregate or statistical information with third parties. This group data will not contain personally identifiable information.

MEMBER WAIVER AND RELEASE:

The Salem Fitness Center recommends a physical examination from a doctor before using any exercise equipment or participation in any exercise class. All exercise, training and/or instruction, including the use of weights and use of any and all machinery, equipment and apparatus designed for exercise shall be at the member’s sole risk. Member understands that the agreement to use, or selection of exercise programs, methods and types of equipment shall be member’s entire responsibility, and the Salem Fitness Center shall not be liable to member for any claims, demands, injuries, damages, or actions arising due to injury to member’s person or of the services, facilities, and premises of the program. Member hereby holds Salem Fitness Center, its officers, owners, agents, and employees or volunteers harmless from all claims which may be brought against them by member or on member’s behalf for any such injuries of claims.

WAIVER OF FUTURE NEGLIGENCE:

Member specifically waives any claim against the Dent County Health Center, the Salem Fitness Center, its officers, directors, agents, employees or volunteers, for any negligent or allegedly negligent act which they may commit or allegedly commit or which may occur or result from any omission or failure to act, in providing services, equipment, training, or any other thing as a part of The Salem Fitness Center’s activities or act or on its premises or resulting from any condition thereon. No such claim shall be permitted, filed, or made and enforced by any court. Member acknowledges that the availability of and access to this program and its facilities and equipment constitutes adequate consideration for this waiver, not withstanding any fees paid by member to said program for said availability and access.

Payment Options

Regular Membership $25.00/month (age 21 – 64) Six Month Discount $125.00

Senior Membership $20.00/month (age 65+)

Household Discount $20.00/member/month (active members sharing the same address)

Guest Membership Weekly Fee $8.00/week Drop-In Fee $5.00/day

Corporate Membership 5 to 10 active members who work at the same location - $20.00/member/month. 11 - 20 active members who work at the same location - $18.00/member/month. Arranged between employer and Fitness Center.

New member Joining Fee $15.00 The Joining Fee plus the first month’s dues are due the day of orientation and the monthly dues shall be due on that day every month. The Joining Fee will be waived if the member pays for three months dues in advance.

In the event that membership dues are not paid, membership would be considered delinquent and membership privileges would be suspended. Please consider paying for 3 months at a time to help defray administrative costs.

I hereby agree to the above terms.

______________________________ __________ ______________________________________ ____________

Member’s Signature Date Witness (Office Staff) Date

Page 1 of 2 The Salem Fitness Center Member Application Effective Jan. 2009

Salem Fitness Center

Medical Screening Questionnaire

Name: __________________________________Age:_____________

Date of Birth: ___________________ Home Phone: ___________________

Physician: ______________________________ Phone: __________________

Yes or No Age and Sex: I am a man over 45 years old; or I am a woman over 55 years old; or I am a woman who has passed menopause or had my ovaries removed.

Yes or No Family History: My father or brother had a heart attack before age 55; or my mother or sister had one before age 65.

Yes or No Blood Pressure: My blood pressure is 140/90mmHg or higher OR I’ve been told my blood pressure is too high.

Yes or No Tobacco Smoke: I smoke.

Yes or No Weight: I am 20 pounds or more overweight.

Yes or No Physical Activity: I get less than 30 minutes of physical activity on most days.

Yes or No Cholesterol: My total cholesterol is 240 mg/dL or higher.

My HDL ("good") cholesterol is less than 35 mg/dL. The last time I had my cholesterol checked was _________________

Yes or No Heart Disease/ Stroke Medical History I have coronary heart disease, atrial fibrillation or other heart conditions; or I’ve had a heart attack. I’ve been told that I have carotid artery disease; or I’ve had a stroke or TIA (transient Ischemic attack).

Cardiac Rehab: Have you ever begun, participated or completed cardiac rehab? Date:_________

Yes or No Diabetes: I have diabetes (a fasting blood sugar of 126mg/dL or higher).

Yes or No Medication: Are you currently on medication? If so, provide complete list.

Yes or No Do you have any joint disease, arthritis, or prior lower extremity injury or chronic recurrent back pain? _______________________________________________________________________

Have you had a recent hip, knee, or shoulder replacement? Date: ________________________

Yes or No Are there any limitations (not previously addressed) which might require special attention in an exercise program? Explain ______________________________________________________

_____________________________________________________________________________

GOALS:

What do you want to focus on in beginning an exercise program?_____________________________________

_________________________________________________________________________________________

Page 2 of 2 Revised 4/24/2009