Purchase College Fitness Program Membership Form

PLEASE FILL OUT ALL FIELDS. ONCE SUBMITTED PLEASE BRING CASH OR CHECK IN PERSON TO COMPLETE THE REGISTRATION PROCESS.

Spring Semester - 1/27/25 through 5/9/25

*Closed 3/22-3/30 for Spring Break*

Fitness Center

Monday through Friday 8:00am-10:00pm
Saturday and Sunday 1:00pm-5:00pm

Pool - Open Lap Swim *opens 2/3/25*

Monday through Friday 12:00pm-2:30pm

Monday through Thursday 8:00pm-9:45pm

Saturday and Sunday 1:00pm-5:00pm

Open Pickleball

Tuesdays and Fridays 8:00am-10:00am

Racquetball/Tennis Courts

by appointment only

Spring 2025*

Individual - $325Family - $465each additional family member less than 18 yrs - $255Senior Citizen (62 years and older) 10% discount - $292Alumni (must show current alumni card) - $260PepsiCo Employee - $225Broadview Resident - $155

BY APPOINTMENT ONLY- please select a time and date below that you would like to come to complete the registration process. Payment can be submitted to Adam Taraska on the 3rd floor office area.

Date you plan to drop off cash or check*

Date

Time*

First Name*

Last Name*

E-mail*

example@example.com

Phone Number*

Street Address 1*

Street Address 2

City, State, Zip*

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Membership includes use of the pool, fitness center, racquetball courts, squash courts, outdoor tennis, locker rooms, saunas.

Individual membership is defined as any person 18 years or older. Family membership is defined as two persons (married couple, domestic partners, or a parent w/ family members under 18 years old). Each individual family member less than 18 years old may be registered for an additional charge.

Number of Additional Family Members (for Family Membership)

Lockers are available as part of the membership fee. Locker registration allows use of a specific locker with your own lock for the duration of the membership period.

ALL LOCKS AND LOCKER CONTENTS MUST BE CLEARED BY THE EXPIRATION DATE ALL CONTENTS WILL BE DISCARDED AFTER THE SEMESTER ENDS

LOCKER ROOM

MaleFemaleNeither

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

***PLEASE FILL OUT ALL QUESTIONS***

Your application will not be accepted if all questions are not answered Regular physical activity is healthy and safe for most people. However, some people should check with their physician before they start becoming more physically active. If you are planning on becoming more pyisycally acitve than you are now, you should start by filling out this questionnaire and undergoing a medical examination from your personal physician. This questionnaire is not a subsitute for a medicam exam and should be answered as accurately and honestly as possible. If you feel you have any medical conditions that may be harmful to you, Purchase College strongly reccomends that you seek medical attendtion before beginning an exercise program.

Do you exercise regularly?*

yesno

Have you ever been told by a physician not to exercise?*

yesno

Do you currently have an illness or infection?*

yesno

Please specify

Have you had surgery or been hospitalized in the past year?*

yesno

Please specify

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Are you currently on any medications?*

yesno

Please specify

Do any of the following apply to you?

Diabetes*

yesno

Liver disorder/disease*

yesno

Kidney disorder/disease*

yesno

High blood pressure*

yesno

Currently pregnant?*

yesnoN/A

Abnormal mentstrual cycle*

yesnoN/A

Cardiovascular history: With mild to moderate exertion do the following apply to you?

Chest Pain*

yesno

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Shortness of breath*

yesno

Pain in legs or arms*

yesno

Dizziness or fainting*

yesno

Do you have a known heart condition*

yesno

Please specify

Pulmonary History: Do any of the following apply to you?

Asthma*

yesno

Emphysema*

yesno

Sport induced Asthma*

yesno

Current smoker*

yesno

Do you have a known pulmonary condition?*

yesno

Please specify

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Musculoskeletal History: Do any of the following apply to you?

Do you have a known musculoskeletal condition?

yesno

Please specify

Arthritis*

yesno

Osteoporosis*

yesno

Multiple Sclerosis*

yesno

Muscular Dystrophy*

yesno

I agree to abide by the regulations of the fitness program. I realize the refund policy for membership cancellation is 100% during week 1, and 70% during week 2, and that the facitily is closed when classes are not in session unless otherwise announced. The program reserves the right to terminate membership without refund if rules and regulations are not abided by or if innapropriate behavior is exhibited. Classes, intramurals, athletics and special events have priority in the facility, and hours are subject to change. Locker contents will be discarded after the expiration date of the membership.

Signature

Date

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REGISTRATION/PAYMENT HOURS:

LOCKER REGISTRATION