Spirit Club

Program Enrollment 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 / Legal Representative 1) agrees to provide supervision and support for Member as determined by SPIRIT Club, and agrees to have full supervision provided before and after specific program start and end times 2) agrees to pay SPIRIT Club the amount indicated on Program Enrollment form 3) accepts that there are no guarantees as to the efficacy of SPIRIT Club services 4) acknowledges that the Member must cancel any Custom Training session at least 12 hours in advance in order to avoid being charged for that session 5) acknowledges that they are legally qualified to sign documents on behalf of the Member 6) accepts that it is the responsibility of the Member to present written submission to the SPIRIT Club regarding updates and/or changes to any information provided on these forms 7) agrees that no individual other than a SPIRIT Club Trainer may conduct, instruct or implement any exercise, stretch or movement for the Member

MEMBER'S PHYSICAL CONDITION - The Member / Legal Representative acknowledges that 1) the information provided on the attached forms 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 participating in any SPIRIT Club program, or using any SPIRIT Club equipment without injury to the Member or impairment to the Member’s health 4) the Member has disclosed special exercise requirements or limitations to SPIRIT Club

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 Fit and Health LLC (hereinafter referred to as “SPIRIT Club”) or any SPIRIT Club Representative (employee, independent contractor, volunteer or other individual affiliated with the SPIRIT Club), for any loss; 2) releases, discharges, holds harmless & indemnifies the SPIRIT Club and any SPIRIT Club Representative, and covenants not to sue SPIRIT Club or any SPIRIT Club Representative, with respect to, any and all now existing or hereafter arising claims, losses, injuries (including, without limitation, death), causes of action, suits, judgments, 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 has 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 SPIRIT Club; 6) confirms a negative response to all questions on the attached Physical Activity Readiness Questionnaire (PAR-Q), or if any responses were positive, the Member has consulted a licensed physician concerning SPIRIT Club’s exercise programs, and the Member’s physician has approved the Member’s contemplated participation in SPIRIT Club’s programs; 7) acknowledges that he/she is legally qualified to sign documents on behalf of the Member.

GROUP PROGRAMS - The Member / Legal Representative agrees that SPIRIT Club is responsible for offering Group Classes over a minimum of 48 weeks per year. Up to 4 weeks of classes per year may be cancelled due to holidays, inclement weather, or any other circumstance. Member is enrolled in advance for specific weekly class(es) for the upcoming month. If a class is missed, the member has the option to attend a make-up class within that month. After the month ends, any classes that were missed can no longer be made up unless they were missed due to a recorded, medical issue. In order to attend any class other than the one(s) originally specified, the Member must submit a written request to a SPIRIT Club staff member, 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.

SCHOLARSHIPS / OUTSIDE FUNDING - The Member / Legal Representative agrees that outside funding may be used to pay for SPIRIT Club services, however Member must receive written confirmation from the outside funding party prior to receiving the discounted rate from the SPIRIT Club.

APPEARANCE RELEASE - The Member / Legal Representative agrees that SPIRIT Club may use Member’s appearance for the purpose of promoting health, wellness and community integration. Member waives right of inspection or approval of appearance, and any right to reimbursement, compensation or other remuneration for SPIRIT Club’s use of Member's appearance. Member acknowledges that he/she may revoke this release with written request to SPIRIT Club at any time which will be effective for any future uses of appearance.

I agree

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