Gold Gym Membership First Name * First Last Name * Last Address * Address Address Address City City Province Province Postal Code Postal Code Phone * Email * Birthdate * Membership Start Date * Emergency Contact Name * Relationship to Applicant * Emergency Contact Phone # * Membership Duration (3 Month Min. for New Customers/Annual for Returning Members.) * Recurring Pre-existing medical conditions Diabetes Heart disease Chest pains Shortness of breath Broken bones Allergies Heart murmur Pneumonia Epilepsy Tachycardia Edema Heart attack Recent surgery Palpitations High blood pressure Low blood pressure Asthma Seizures Fainting Additional Medical Notes RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS AGREEMENT I, the undersigned, waive all rights for myself, my heirs, successors, executors, administrators and assigns, and release Beyond Basics Fitness & Nutrition, its employees, agents, contractors and relatives, from all claims, without limitation for any and all personal injuries suffered by me as a result of my use of the Beyond Basics Gym, its’ equipment, facilities or my presence anywhere on Beyond Basics property, and participation in any event(s) or workshops within the Beyond Basics Fitness or Educational Activities on or off Beyond Basics property. I am aware that the physical exertion required of the Fitness Activities and the forces exerted on the body can activate or aggravate pre-existing physical injuries, conditions, symptoms or congenital defects. I have been advised to seek medical advice prior to participating in Fitness Activities. I have no reason to believe that my physical condition may be incompatible with such activities. I freely accept and fully assume all risks, dangers and hazards associated with the fitness activities and the possibility of personal injury, death, property damage or loss resulting therefrom. I also acknowledge that should I suffer personal injury while participating in on or off site fitness activities, that Workers' Compensaton Coverage will not apply. (PLEASE TYPE YOUR FIRST AND LAST NAME AND ADD YOUR SIGNATURE BELOW IN AGREEMENT WITH THE BEYOND BASICS GYM MEMBERSHIP CONTRACT, GYM RULES & GUIDELINES, AND WAIVER.) Name * Name First First Last Last Signature * Clear Submit Δ
