The CORE Fitness Center Membership

Welcome sheet - Member's Information

All members or guests must fill out this form before using the fitness center. All information is confidential.
Full name*

First NameLast Name
Birth Date*

MonthDayYear
Please print off form and return to Finance Desk at Prairie College with your payment.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
Emergency contact*

First NameLast Name
Phone number*

Area CodePhone Number
Health Questionnaire
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Health Conditions*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials*

Clear
Liability waiver
I hereby release Prairie College and its employees from any and all claims or any damages whatsoever arising out of any accident or injury which may be caused by or results from any participation while engaging in activities at or sponsered by The Core Fitness Center. I further agree that I, the undersigned, have no knowledge of any physical illness or disability that through my participation could prove dangerous or hazardous to my health.

I have been provided the fitness center policies and agree to abide by them.

I understand that fitness staff are not on duty during all operating hours. There may be times when there is no direct staff supervision. I am aware that I should exercise caution while using fitness equpiment and/or engaging in a fitness activity I am unfamiliar with.

The Core Fitness Center reserves the right to suspend or revoke any fitness membership in the event of inappropriate behavior and/or failure to follow Fitness Center policies by the member and/or the member's guests.

Personal Information on this form is collected for the purpose of entering membership information into the registration system and will not be used for any other purpose.
Initials*

Clear
Billing

Info & Costs
Information

College Students & Staff are free to use the gym.

Local students (14-17 years)

Year membership - $120.75

6 Month - $73.50

Community (18+ years)

$47.25 for new 1 month memberships/ $34.13 for renewals

$94.50 for new 3 month memberships/ $70.88 for renewals

$278.25 for 1 year membership/ $244.13 for renewals

Alumni

$173.25 for 1 year membership

All Prices Include GST
Select One

New: For those who are new to our facilitiesRenewal: For those needing to renew their membership
Costs - Select One*

College Student/Staff (Free to use the gym)Local Student (14-17 years) ($120.75 1 Year)Local Student (14-17 years) ($73.50 6 months)Community (18+) ($47.25 New 1 Month)Community (18+) ($34.13 Renewal 1 Month)Community (18+) ($94.50 New 3 Month)Community (18+) ($70.88 Renewal 3 Month)Community (18+) ($278.25 New 1 Year)Community (18+) ($244.13 Renewal 1 year)Alumni ($173.25 1 Year)
Select Payment Type*

Credit Card (below) (New Memberships, see Finance Desk)Debit Card (Finance Desk at Maxwell Center)Cash (Finance Desk at Maxwell Center)

Membership Registration

1 Month New Membership$47.25CAD

Community 18+

I Month Renewal$34.13CAD

Community 18+

3 Month New Membership$94.50CAD

Community 18+

3 Month Renewal$70.88CAD

Community 18+

Year New Membership$278.25CAD

Community 18+

Year Membership Renewal$244.13CAD

Community 18+

Local Student 6 Month Membership$73.50CAD

14-17 years

Local Student Year Membership$120.75CAD

14-17 years

Alumni Year Membership$173.25CAD

Alumni

Total $0.00CAD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Signature*

Clear
If you are a family member of staff or faculty, please write their name here.
Should be Empty:

Welcome sheet - Member's Information

Health Questionnaire

Liability waiver

Billing