Gym health questionnaire Form

Dear Vallied Gym Member, please be advised that completion of this update form is a requirement for your new key code activation. This update form will help the gym staff better manage members and member safety. Signing also confirms that each member understands the importance of monthly gym membership fees; it also confirms that each member understands the importance of proper replacement of any weights used when done in the gym.
- If monthly payments are not made within three (3) days of your membership due date (which will include a $5/day late fee) the your membership will be canceled.
- If weights are not returned to their proper stations to reduce tripping hazards a safety investigation fee of $20 will be required to unlock your membership code. You will be notified of the violation. A second violation will result in your membership being canceled.
- If you choose to return after 30 days has passed, you will be required to return at a quarterly member payment rate that will be subject to immediate cancellation if you violate this agreement again. You will be charged with trespassing if you refuse to leave or return without permission.
- These changes are to help with proper management of the gym as well as enforce safety for all members...thank you in advance for your consideration and understanding of this new and updated intake policy.
The Healthier Liz Gym Application

Please attach a copy of a Valid pic ID
Multiple Photo IDs can be uploaded here

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per applicant within the same household. Cancelof
Full name*

First NameLast Name
Birth Date

MonthDayYear
Additional Family Member (must pay membership fee)

First NameLast Name
Birth Date

MonthDayYear
Additional Family Member (must pay membership fee)

First NameLast Name
Birth Date

MonthDayYear
Additional Family Member

First NameLast Name
Birth Date

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com of main applicant
Phone Number*

Area CodePhone Number
Emergency contact*

First NameLast Name
Phone number*

Area CodePhone Number
Clients informations - Health questionnaire (Par-Q)
Self evaluation or consulting physician is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q*

	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 faint 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
Client informations - Liability waiver
I am aware of the risks in observing or participating in the activities offered and sponsored by The Healthier Liz and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death.
Initials*

Clear
Client informations - 48h cancellation policy

refunds will not be given to payments already made.
All cancellations must be received at least 24h before your training session in order to avoid being charged. Clients who do not cancel with 24h notice will be charged 50% of a regular price session for the cancellation.

The Healthier Liz understands that emergencies happen. We provide every client with one free short-notice cancellation. You will not be charged for your first cancellation with less than 24h notice. Subsequent short notice cancellations will be charged for the session. The free short-notice cancellation only applies if The Healthier Liz staff is notified prior to the session start time. No show are not eligible for the free cancellation.
Initials*

Clear
Client informations - Billing policy
I authorize The Healthier Liz to bill my credit/debit card monthly on the date of my original application.
Initials*

Clear
Client informations - Signature
Signature*

Clear

General Membership

Date*

MonthDayYear
DateHourMinutesAM/PM Option
Should be Empty:

The Healthier Liz Gym Application

Clients informations - Health questionnaire (Par-Q)

Client informations - Liability waiver

Client informations - 48h cancellation policy

Client informations - Billing policy

Client informations - Signature

Payment Methods