New Membership Form
Customer Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Place of Employment
Emergency Contact Person
First Name
Last Name
Relationship
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Ethinicity
Please Select
White/Non Hispanic
American Indian
Black/ Non Hispanic
Hispanic
Asian/Pacific Islander
Type of Membership
Single
Couple
Family
If Family membership Names of Members and dates of Birth for Each
First Name
Last Name
Card Number
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If Family membership Names of Members and dates of Birth for Each
First Name
Last Name
Card Number
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type a question
Arthritis
Asthma
Bleeding Tendency
Congenial Heart Disease
Diabetes
Emphysema
Visual Problems
Hearing Problems
Severe Dizziness
Fainting/Blackouts
Severe Headaches
Head Injury
Heart Attack
High Blood Pressure
Stroke
Chest Pain
Heart Palpitation
Neck Injury
Back Injury
Muscle/Tendon Injury
Shortness of Breath
Recent Surgey
Hernia
Are you Currently under a Doctors care for any of the above, If so please explain
Name of Doctor
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you Smoke/Packs per week
Do you Drink Coffee/Tea-Cups/Glass per week
Do you Drink Alcohol/Beer per week
I Consider Myself
Overweight
Underweight
The right weight
Basically in shape
Somewhat in shape
Totally out of shape
I Currently Exercise
Once a week
Twice a week
Three times a week
Three (plus) times a week
None
Occasionally
Person to Contact in Emergency
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Member or Applicant: I understand that although the facilities, equipment, services and programs of the YWCA Fitness Connection program are designed to provide a safe level of beneficial exercise and enjoyment, there is an inherent risk that use of such facilities, equipment, services and programs may result in injury to me. The risks include, but are not limited to: 1. Injuries arising from any exercise equipment and machines. 2. Injuries arising from participation in supervised or unsupervised activities and programs in the swimming pool, the exercise rooms, or any other areas of the YWCA building. 3. Injuries or medical discords resulting from exercising at the facility including but not limited to, heart attacks, strokes, heat stress, sprains, broken bones and torn muscles or ligaments. 4. Accidental injuries within the facilities, including but not limited to, the locker rooms, whirlpool, sauna, showers and dressing rooms. I also acknowledge the existence and the need for Rules and Regulations including those governing the use of the Fitness Connection program’s equipment and facilities and participation in various YWCA programs and services. I hereby agree to comply with those Rules and Regulations and to amendments or additions to them as the YWCA decides are necessary. I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS AND I SPECIFICALLY AGREE TO ASSUME ALL RISK OF INJURY TO ME WHILE USING ANY OF THE YWCA EQUIPMENT, SERVICES OR PROGRAMS. I HEREBY WAIVE ANY AND ALL CLAIMS OR ACTIONS I OR ANY OF MY MINOR CHILDREN MAY HAVE AGAINST THE YWCA OR ITS BOARD MEMBERS AND TO HOLD THE YWCA EMPLOYEES OR BOARD MEMBERS HARMLESS FROM ANY AND ALL CLAIMS RESULTING FROM SUCH INJURY TO ME OR TO MY MINOR CHILDREN.
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