Clinic Registration

Una's Spring 2012 Run Clinics

* = REQUIRED INPUT

*Clinic:

*First Name:

*Last Name:

*Age:

*Gender: Male Female

*Email address:

*Home Phone: (xxx-xxx-xxxx)

*Do you want a 24-hour reminder email? No Yes

"PAR-Q" Health Screening Questionnaire

*Doctor:

*Have you had a serious injury recently? No Yes » specify:

*Has your doctor ever said that you have a heart condition and recommended only medically supervised activity? No Yes

*Do you suffer chest pain when exercising? No Yes

*Have you had chest pain in the last month? No Yes

*Do you lose consciousness or fall over? No Yes

*Do you have any bone or joint problems that could be aggravated by physical activity? No Yes

*Has your doctor ever recommended medication for your blood pressure or a heart condition? No Yes

*Is there any other reason that you are aware of that may preclude you from exercising? No Yes

*Are you over age 65 and not accustomed to vigorous exercise? No Yes

*Are you diabetic? No Yes

Do you have allergies? Are you on any medications? Do you have a medical condition not referred to above? If yes to any, please explain:

I have answered the above questions to the best of my ability. I understand that, if I answered YES to any of them, it is MY responsibility to discuss this with my physician. I understand that I am free to use any equipment in Avid Fitness Center Ltd. but am encouraged to ask for assistance from a staff member if there is any question as to its safe use or possible effect on any condition that I may have or suspect I have. I understand that, as a member of this facility, I am able to ask for assistance in the proper and safe use of the equipment. HOWEVER, I UNDERSTAND THAT I AM NOT CONSIDERED TO BE ENROLLED IN ANY SUPERVISED REHABILITATION OR OTHER SUCH PROGRAM.

I agree with the above statement

AVID Drop-In Waiver

WELCOME TO TO AVID FITNESS CENTER LTD. TO ENSURE YOUR SAFETY, PLEASE READ & AGREE TO THE FOLLOWING...

The undersigned voluntarily assumes all risks related to the Released Matters as hereinafter defined. The undersigned hereby releases Avid Fitness Center Ltd., its directors, officers, employees, contractors, agents and invitees (including other customers) from any claim for any property damage, loss, personal injury, death, illness, disability, deterioration and/or aggravation of condition, arising out of or in connection with the use of the Avid Fitness Center Ltd. facilities and/or the equipment and/or participation in any activities or program of Avid Fitness Center Ltd. at its premises or elsewhere, no matter how caused and whether caused by negligence or otherwise (all of the foregoing being the “Released Matters”). Any adult, parent or guardian who signs this form on behalf of a minor, and agrees that he/she has the authority to sign and to bind the minor, and agrees to indemnify and save harmless Avid Fitness Center Ltd. or its directors, officers, employees, contractors, agents and invitees (including other customers) from any claim by or on behalf of the minor regarding any of the Released Matters.

The undersigned agrees to abide by the rules and regulations of Avid Fitness Center Ltd. The undersigned agrees that he/she is responsible for any damages caused by him/her to the facilities and equipment of Avid Fitness Center Ltd.

BY SIGNING THIS SHEET, THE UNDERSIGNED IS ACKNOWLEDGING AND ACCEPTING THE INHERENT RISKS INVOLVED IN RIGOROUS EXERCISE AND THE USE OF EXERCISE EQUIPMENT.

IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING THE USE OF EQUIPMENT, PLEASE ASK!

If you are under the age of 19 years you will need your parent or guardian to accept this waiver.

I agree with the waiver

Parent or Guardian name if applicant is under 19:

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