Trial Membership

Fitness Point, LLC Waiver of Liability

Name: Date:
Address: DOB:
City: State: Zip:
Home Phone: Cell Phone: Work Phone:
Email Address:
Trial Weeks:    □  1 Week        □  2 Weeks        □  3 Weeks       □  1 Month
Starting Date: Ending Date:

Any medical problems that should be known:

□  yes   □  no  Physician is aware of you and your family participating in this exercise program.
□  yes   □  no   Presently not taking any medications or drugs. 
□  yes   □  no   History of heart problems, chest pain or stroke
□  yes   □  no   Increased blood pressure
□  yes   □  no  Any chronic illness or condition
□  yes   □  no   Advice from physician not to exercise
□  yes   □  no   Recent surgery (Last 12 months)
□  yes   □  no   Pregnancy (Now or within last 3 months)
□  yes   □  no   History of breathing or lung problems
□  yes   □  no   Muscle, joint or back disorder
□  yes   □  no   Diabetes or thyroid condition
□  yes   □  no   Cigarette smoking habit
□  yes   □  no   Increased blood cholesterol
□  yes   □  no   History of heart problems in immediate family
□  yes   □  no   Hernia or condition aggravated by lifting weights.
□  yes   □  no  Any other problems or surgeries that should be know, please write in below: 

 

 
  

Waiver of Liability Claim: 
It is expressly agreed that guest’s sole risk shall undertake all activities and use of all facilities. Fitness Point, LLC,  shall not be liable for any claims, demands, injuries, damages or actions whatsoever to guest or guest’s property arising out of or connected with use of any of the services and facilities of the club or the grounds on which the club is located. The guest does expressly forever release and discharge the club from all such claims, demands, injuries, damages or actions and from all acts of active or passive negligence on the part of Tom and/or Amanda Ingwell, who own the club, its partners, agents and employees.

Print Name____________________________

Signature _________________________________   Date _____/_____/_____

 

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