New Customer Registration Form

Cornwell Center Membership Application
Responsible party
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex

FemaleMaleN/A
Phone Number*
E-mail*
example@example.com
spouse/partner
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex

FemaleMaleN/A
Phone Number
E-mail
example@example.com
children

(dependents age 12 +)
Full Name
Date of Birth

MonthDayYear
Date
Full Name
Date of Birth

MonthDayYear
Date
Full Name
Date of Birth

MonthDayYear
Date
address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
emergency contact
Full Name*
Relation*
Phone Number*
membership type
Monthly Memberships*

StudentIndividualHouseholdSenior IndividualSenior HouseholdSupplemental Insurance
Are you a member of MPBC?*

YesNo
Do you have supplemental Insurance?*

NoRenew ActiveSilver & FitAARP Medicare SupplementSilver SneakersFit On Health
Waiver, Release, Indemnification and Covenant Not to Sue
I, Full Name* , the undersigned, agree to release, and on behalf of myself, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE Myers Park Baptist Church - its officers, directors, employees, volunteers, agents, representatives and insurers ("Releasees") from any causes of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I, my heirs, representatives, executors, administrators and assigns may have, now or in the future, against Myers Park Baptist Church on account of personal injury, property damage, death or accident of any kind, arising out of or in any way not limited to the negligence of Releasees.

I, the undersigned, agree to INDEMNIFY AND HOLD HARMLESS Releases from any and all causes of action, claims, demands, losses, or costs of any nature whatsoever arising out of or in any way related to my presence on the campus of Myers Park Baptist Church.
Signature*

Clear
Date*

MonthDayYear
Date
Waiver, Other Risks
It is understood by the undersigned that there are certain risks inherent in the activities conducted at the Cornwell Center, which I agree to assume on behalf of myself and/or family members. To the extent allowed by applicable law I agree to hold the Cornwell Center, its agents and employees, harmless from any claim on behalf of myself and/or my family members arising out of any loss, injury, or death attributed to such risks. All participants in the physical fitness programs of the Cornwell Center are hereby informed that these programs involve strenuous activities. It is the obligation of all participants in such programs to advise the staff if they suffer from fatigue, shortness of breath, chest discomfort, pain or any similar occurrence which may jeopardize their health. By participating in any of the physical fitness programs of the Cornwell Center, each participant acknowledges and consents to the duty described above. Participants are encouraged to ask the staff questions about the physical fitness programs and to follow the directions of the instructos and coaches with care. Rules and regulations have been adopted for the safe enjoymnet of this facility by all participants. I agree to adhere to those regulations. The Cornwell Center reserves the right to take necessary disciplinary action including membership revocation if these rules are not followed. I hereby give permission for the Cornwell Center staff to secure medical treatment for myself or my family in the event of an emergency. I also authorize the physician or medical personnel selected to provide treatment demmed necessary by them. The Cornwell Center may use participation photographs or videos taken of myself or my family for marketing and advertising purposes. I certify, to the best of my ability, that the accompanying information is correct and accurate.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Cornwell Center Membership Application

Responsible party

spouse/partner

children

address

emergency contact

membership type

Waiver, Release, Indemnification and Covenant Not to Sue

Waiver, Other Risks