HealthQuest Membership Agreement Form

Full Name*

First NameLast Name

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.

Home Address*

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Date of Birth*

MonthDayYear

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone*

Please enter a valid phone number.

If purchasing a family membership, list your family members first & last names & dates of birth (e.g. spouse, children at least 16-years-old living in same household; limit of 4 total members).

File Upload*

Upload a recent photo of each new member (1-4 photos).

DEFAULT & LATE PAYMENT: Should you default on any paymentobligation called for in this agreement, the entire remaining balance shall be deemed due and payable upon demand, and you agree to pay allowable interest, and all cost of collection, including, but not limited to collection agency fees, court costs, and attorneys’ fees. Should any monthly payment become more than 10 days past due, you will be charged a late fee of $10 per month for insufficient funds.

CANCELLATION OF MEMBERSHIP
If by reason of death or permanent disability, the buyer is unable to continue membership or moves 25 miles from the address of HealthQuest Fitness Center, payment of this agreement will be suspended.

You must provide notice, in writing, of cancellation by the 20th of the month prior to the month you wish to cancel.

Any holder of this contract is subject to all claims and defenses which the buyer/member could assert against the club as a result of this contract. Recovery shall not exceed the total amount paid by the buyer/member to cancel this agreement by midnight of HealthQuest’s 3rd business day after the date of this agreement.

WAIVER & RELEASE OF LIABILITY
HealthQuest Fitness Center urges you and all members to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise class. All exercises, including the use of any and all equipment shall be at the member’s sole risk.

Member understands that the agreement to use, or selection of exercise programs, methods and types of equipment shall be member’s (& family’s) entire responsibility, and the Club shall not be liable to mem- ber for any claims, demands, injuries, damages, or actions arising due to injury to member’s person or property arising out of or in connection with the use by member of the services, facilities, and premises of HealthQuest Fitness Center. Member hereby holds HealthQuest Fitness Center, its officer, owners, agents and employees harmless from all claims which may be brought against them by member, member’s family or on member’s behalf for any such injuries or claims.

I, the undersigned member/guest, do hereby agree that HEALTHQUEST is free of any and all responsibility and liability for bodily injury, accident, or theft of personal property that may occur during my use of said premises.

By my signature, I do hereby accept the terms stated above and exempt HEALTHQUEST from any and all obligations.

By signing below, I acknowledge that I have read, understand, and agree to comply with all terms and conditions outlined in this membership agreement, including HealthQuest Fitness Center's Rules & Regulations.

Signature*

Terms and Conditions*

Note:

Six-month membership payments (taken out of checking or savings account monthly) require a one-time $15 EFT fee at sign up.
Entrance cards are $10 each or key fob is $20.
Sales tax will be added to membership prices.
Note: For family memberships, couples must be legally married. Limit 4 total members, and offspring must live in same household.

My Products*

Single One-Month Membership(Includes sales tax)

$40.39 Quantity

Family One-Month Membership

$51.09 Quantity

Single Six-Month Membership Paid Up Front(Includes Sales Tax)

$197.40

Family Six-Month Membership Paid Up-Front(Includes Sales Tax)

$261.62

Single Six-Month Membership (Paying first month up front and the one-time EFT fee. You will be contacted for account information to pay remaining months @ $30.75 cost plus sales tax) You must also complete the EFT Authorization Form for monthly payments. https://form.jotform.com/252996298899085

$45.75 Quantity

Family Six-Month Membership (Paying first month up front and the one-time EFT fee. You will be contacted for account information to pay remaining months @ $40.75 cost plus sales tax). You must also complete the EFT Authorization Form for monthly payments. https://form.jotform.com/252996298899085

$55.75 Quantity

Entrance FobPurchase a fob for each member, up to four (4).

$20.00 Quantity

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card