Adult Fitness Trial Membership Intake

Trial Membership Price - $137 and is nonrefundable.
Putting the trial period on pause once started is not permitted for any reason.
This form is also a liability waiver and must be completed and signed by the trial member.
A trial membership does not automatically rollover into membership

If you want to sign another adult up for classes, they must complete the intake form. However, you can pay for their trial by adding a second trial in your cart at checkout when paying.

Text 503-537-0104 with any other questions.

After completing and signing this form, you will be directed to a secure website to make your payment. An Impact team member will reach out to schedule initial classes. Please allow at least 24 hours to be contacted and if registering over the weekend or holiday, please allow until the next business day. Do not show up for your first class unless it has been scheduled.

Name *

First NameLast Name

Mobile Number*

Please enter a valid phone number.

Email*

example@example.com

Date of Birth

Date

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Would you like to include an assessment prior to beginning your first class?*

Yes, I would love to meet with a coach prior to starting a group class!No thanks, I'm ready to start!

Tell us more why you are interested in a fitness membership by checking those that apply below:*

Returning to a consistent fitness routineNew to fitness and want coaching supportBe part of a fitness communityWant to become leanerWant to become strongerWant to improve my joint strength and range of motion (mobility)Trying to improve my overall healthOther

Would you be interested in trying Brazilian Jiu Jitsu classes during your fitness trial (at no additional charge)?*

Yes, I would love that!No thanks, I'll just focus on fitness for now

What best describes your learning style?*

Understand there is a learning curveEasily frustratedSomewhere between the first two options

List any current or past health issues/injuries/behaviors (and approximate date) you want to share with our coaches.

Have you been diagnosed with any medical conditions or prescribed medications which can affect your training or that coaches should be made aware?*

YesNo

If yes, briefly describe your conditions and/or any medications prescribed below.

I certify and represent that I am at least 18 years of age and signing this document on behalf of myself and no other person.

I agree that all training and safety recommendations given are undertaken at the sole risk of myself. Newberg BJJ, LLC dba Impact Training Center (referred to as GYM) is not liable for any claims for injuries or damages, whatsoever, to me or my property arising out of, or in connection with attending and participating in classes provided by GYM, or any actions taken within the facility outside of a coach’s supervision or without permission. I agree to indemnify and hold harmless GYM, its owner, employees, subcontractors, and representatives from all claims of liability by me.

I agree to abide by any rules and regulations issued by GYM. Failure to do so may result in expulsion from training and the forfeiture of all monies paid to the GYM.

I give GYM the irrevocable right to use video or photograph in all forms of media, including composites for social media, advertising, publication, or any other lawful purposes, and waive any right to inspect or approve the finished product, including written copy created in connection with the image.

The Gym, owner, agents, and employees shall not be responsible for damaged, lost or stolen articles, inside or outside the facility.

I understand this is a waiver and release of liability and I voluntarily agree to its terms.

Signature*

Adult Trial Membership Intake