Club 14 Fitness
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Adult Medical Form & 24 Hr Waiver
Minor Permission Form
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Medical Questionnaire
Full Name
*
First Name
Last Name
E-mail
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Sex
Male
Female
Height
Weight
Marital Status
Single
Married
Divorced
Widowed
Living with S/O
Do you live a sedentary (inactive) lifestyle?
Yes
No
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you do physical activity?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes
No
Is your doctor currently prescribing any drugs for your blood pressure or heart condition?
Yes
No
Do you know any other reason why you should not perform physical activity?
Yes
No
If you have answered YES to the above, please list:
Physician
Signature
Club 14 Fitness 24 Hr Waiver
Congratulations and thank you for purchasing a membership at our facility! We are honored to provide you access at any time to CLUB 14 FITNESS. We consider this lovely facility our home and hope you feel the same. As such, you are aware that there will be no supervision or assistance and we ask that you treat the facility in a respectful manner, adhering to the following:
You (each member, guest, or participant) agree that if you engage in any physical exercise or activity, or use any CLUB14 FITNESS amenity on or off premises including any sponsored club event, you do so entirely at your own risk. You agree that you are voluntarily participating in the use of this facility and assume all risks of injury, illness, or death.
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Your access card is for you and you alone. You agree not to share with anyone.
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You are required to bring a sweat towel.
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CLUB 14 FITNESS is not responsible for any loss of your personal property.
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You agree to put away all equipment used during your workout. This includes, but is NOT limited to: dumbbells, weight plates, barbells, accessories, pvc pipes, mats, jump ropes, weight belts, foam rollers, benches, etc. You understand that repeated failure to do so may result in an automatic $15 fee charge to your member account.
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You agree to allow access to the after-hours door to NO ONE other than yourself. You understand and accept that a $50 charge to your account will be assessed if you violate this rule.
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Additionally, you recognize this is a violation, and personally take on any and all legal liability should injury occur, to your unauthorized guest(s).
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*Exception to rule - CLUB 14 FITNESS has made provision for a member’s personal guest(s) only after-hours. Please have them sign the guest register and deposit guest fee of $15 inside club door in the cash box provided or scan the VENMO QR code.
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You are required to wear sneakers for access to Club 14 Fitness. No work boots, flip-flops, etc.
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Signature
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Minor Permission Request
The following is an application for use of CLUB 14 FITNESS. Management will call or email with confirmation of your request. Please fill out this form at least 48 hours prior to need. The parent or guardian listed on the form will be responsible for life and death decisions for this child.Please fill this section out for EACH child separately.
Parent Name
First Name
Last Name
Parent Phone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Minor Name
First Name
Last Name
Minor Date of Birth
-
Month
-
Day
Year
Date
Sex
Male
Female
Prefer Not To Say
C14F Member - Parent is placing their child in custody of (if not the above named parent):
Custodial Name(s):
First Name
Last Name
First Name
Last Name
First Name
Last Name
Phone Number of Primary Custodian
Please enter a valid phone number.
Email of Primary Custodian
example@example.com
*Note: The signing C14F member will be responsible for the life and death of this child
Does this child have diabetes?
Yes
No
Does this child have a family history of coronary heart disease prior to the age of 55?
Yes
No
Has their Doctor ever told you that they had a heart condition?
Yes
No
Does your child ever experience chest pain?
Yes
No
Does your child lead a sedentary (inactive) lifestyle?
Yes
No
Does your child ever experience any joint, bone, or muscles problems (shoulder, knee, etc.)?
Yes
No
Does your child have any chronic low back pain?
Yes
No
Does your child experience unusual fatigue or shortness of breath at rest, fainting, or dizzy spells?
Yes
No
Does your child suffer from asthma, emphysema or other pulmonary disease?
Yes
No
Does your child suffer from epilepsy or seizures?
Yes
No
Is there any other physical disability that could interfere with safe exercise participation?
Yes
No
If the answer to the question above is yes, please explain
Parent Signature
Guardian Signature
As guardian of the minor(s) that I have entered into the Club 14 Fitness facility with, I assume all risks and liability with them. this means Emergency Medical Attention, any financial obligation resulting from our visit, whether liability, stolen property or damage. I understand that the possibility of great harm exists and I assume all the risk.
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Minor Permission Request Form
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