Spirit Club

Registration Form

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Welcome!

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE Yes/No
1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?  Yes No
2. Do you feel pain in your chest when you perform physical activity?  Yes No
3. In the past month, have you had chest pain when you were not performing any physical activity?  Yes No
4. Do you lose your balance because of dizziness or do you ever lose consciousness?  Yes No
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?  Yes No
6. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?  Yes No
7. Do you know of any other reason why you should not engage in physical activity?  Yes No

Member is capable of independently following visual/verbal instructions:  Yes No

Alternate Payment Requested (select if applicable)
 Respite LISS Spirit Club Foundation Other

This agreement incorporates between "Member" and "Spirit Club" according to the Terms & Conditions provided below

GENERAL PROVISIONS - The Member, or person signing on behalf of the Member 1) acknowledges that they are legally qualified to sign documents on behalf of the Member 2) accepts that it is the responsibility of the Member to present written submission to the Spirit Club regarding updates and/or changes to the member information on this form, and acknowledges that unless updates are reported & submitted prior to any training or session, this information shall remain valid for all subsequent programs and services provided.

MEMBER'S PHYSICAL CONDITION - The undersigned acknowledges that 1) the information provided on the "Member Information" sheet is accurate 2) the Member is voluntarily engaging in physical exercise 3) the Member has no physical or mental health conditions, including, without limitation, any cardiovascular, neurological, disease or other condition that will prevent the Member from exercising or participating in, and/or using any Session, equipment, facilities, programs, Group Classes, Customized Training, activities and/or other services or events provided by, or sponsored by, any Spirit Club Entity whether on or off Spirit Club premises without injury to the Member or impairment to the Member's health 4) the Member has consulted a licensed physician concerning an exercise program that will not subject the Member to risk of injury or impairment to health, and the Member's physician has approved the Member's contemplated participation in Spirit Club programs 5) the Member has disclosed special exercise requirements or limitations to Spirit Club 6) the Member confirms a negative response to the following questions, or if response is positive, the Member has followed up with a licensed physician confirming that participation in Spirit Club programs is approved according to the doctor's medical expertise: i. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? ii. Do you feel pain in your chest when you perform physical activity? iii. In the past month, have you had chest pain when you were not performing any physical activity? iv. Do you lose your balance because of dizziness or do you ever lose consciousness? v. Do you have a bone or joint problem that could be made worse by a change in your physical activity? vi. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? vii. Do you know of any other reason why you should not engage in physical activity?

GROUP CLASS MEMBERSHIP - As an Ongoing Member (member on any auto-pay system), the Member agrees to be billed their monthly membership fee on a monthly basis until the Member of Member’s guardian/representative provides written notification to cease their membership. The Member may request to cease their Membership agreement at any time by submitting a written request to the Spirit Club. Upon receipt of a request to cease the Membership, Spirit Club will cease billing within 24 hours, and the Member will be eligible to participate in classes only through the end of that month. The responsibility falls on the Member to submit a written request to terminate the Membership agreement. If the Member is unable to attend classes, and the Member or Member's guardian/representative is unable to submit a written request or contact Spirit Club about termination due to debilitation, Spirit Club will reimburse the Member for payments that took place after debilitation of the Member or Member's guardian for up to 6 months, given that the Member can provide supporting documentation that the Member and/or Member's guardian/representative was unable to submit a written request to terminate the Membership agreement. Spirit Club is responsible for offering Group Classes over a minimum of 48 weeks per year. Spirit Club retains the right to cancel classes due to holidays, inclement weather, or any other circumstance, and for Member convenience, Spirit Club will make all efforts to provide at least 24 hours of notice before a class cancellation. For Group Class enrollment, the Member must commit to attend specific weekly class(es) that must be identified upon enrollment. In order to attend any class other than the one(s) originally specified, the Member must submit a written request, and the Member must receive written approval from a Spirit Club staff member. In order to ensure the safety of Spirit Club Members, Spirit Club retains the right to refuse participation to Members who have not received written approval from Spirit Club to participate in a class other than the class(es) identified upon enrollment.

WAIVER & RELEASE OF LIABILITY - The undersigned 1) waives any and all claims and rights that the Member may now or hereafter have against the Spirit Club or any Spirit Club employee, independent contractor, vendor or other individual affiliated with the Spirit Club, for any loss; and 2) releases, discharges, holds harmless & indemnifies the Spirit Club and any Spirit Club employee, independent contractor, vendor or other individual affiliated with the Spirit Club, and covenants not to sue the Spirit Club or any Spirit Club employee, independent contractor, vendor or other individual affiliated with the Spirit Club, with respect to, any and all now existing or hereafter arising claims, losses, injuries (including, without limitation, death), causes of action, suits, judgements, demands, fees, costs, expenses (including, without limitation, attorneys' fees, costs, and expenses), damages, and other liabilities with respect to any loss. 3) understands that Spirit Club makes no medical claims nor warrants any results from participation in Spirit Club programs 4) acknowledges that Spirit Club has represented to me that its personnel have no expertise in diagnosing, examining, or creating special plans of exercise for individuals with medical conditions, and that Spirit Club cannot determine the effect of any specific exercise on any medical condition 5) recognizes and agrees to assume the risk of injury or illness arising out of the Member's participation with the Spirit Club, and in Spirit Club programs.

APPEARANCE RELEASE - SPIRIT Club will only release appearance of Members in order to encourage community inclusion & integration. The Member agrees to waive any right of inspection or approval of appearance, or to the uses to which such appearance may be put. The Members waives any right to reimbursement, compensation or other remuneration for Spirit Club's use of appearance. The Member may revoke Spirit Club’s right to release the Member’s appearance at any time by submitting written notification to Spirit Club clearly indicating that the Member does not want appearance to be released, however, a revocation will be effective only as to any future uses of appearance, and does not require SPIRIT Club to cease using promotional materials already in use.

SCHOLARSHIPS / OUTSIDE FUNDING - Outside funding may be used to pay for Spirit Club services. The Member must receive written confirmation from the outside funding party prior to receiving the discounted rate from the Spirit Club.

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