Title: First Name: Surname:

Age: Date of Birth: Sex: M or F

Address: Home Phone:

City: Mobile:

County: Postcode: Email:

Membership: Single Joint Joining Fee: Monthly

Fee:

Type: Platinum Gold Silver Bronze Red Student Daily Casual

Joint Membership Number: (If Applicable) Medical History Do you suffer from/have you ever suffered from any of the following: Yes No Heart or blood pressure problems Pains in the chest while exercising Fainting or Dizzy Spells Epilepsy Diabetes Asthma or breathing difficulties Problems with joints Neck or back problems Are you pregnant Any other medical conditions or problems Do you smoke Do you drink alcohol Are you on any medication

Have you consulted your doctor about exercise

If you have checked yes to any of these questions then a GPs referral may be required prior to participation in training activities.

Emergency Contact Information Name:

Contact Number: Relationship:

2

CONDITIONS Management reserves the right to change rules, terms and conditions of the club without prior notice. Management reserves the right to change fees and payments for the good and benefit of the club. Membership cards remain the property of the club and all members will be required to show cards on each and

every visit. Members will conduct themselves in a quiet, well-mannered fashion at all times. The management reserves the right to refuse entry at all times and to terminate memberships with immediate effect. Members expelled will forfeit all privileges of membership. Any complaints unresolved at the time of incident will be referred to and dealt with by the manager. The gym shall be entitled to make alterations, carry out repairs or maintenance without prior notice, though of

course, every consideration will be made to minimise inconvenience. The gym shall not be responsible for the personal belongings of the members or visitors. Additional charges of up to 25 may be incurred for any unpaid Direct Debits. No refunds for non-usage of clubs facilities. Photograph compulsory. The gym reserves the right to amend the terms & conditions from time to time. Unpaid Direct Debits will be reclaimed on or just after 10th of relevant claim month without prior written or verbal

notice. Gold Members can change the membership package only once they are out of their 12 month contract Members can change their membership package between Bronze, Red and Causal as often as they wish. The gym shall not be responsible for the injury of a person through miss use of the equipment or facilities. All members must notify management, in writing, of any changes to their health.

DISCLAIMER I confirm that the information I have given is correct and agree to inform Muscle Fury Boutique gym and Nutrition Centre of any changes in my status before continuing with my exercise program. I hereby state that I have read, understood and answered honestly the pre exercise questionnaire. Any questions I had were answered to my full satisfaction. I also state that I wish to participate in all the activities provided by Muscle Fury Boutique gym and Nutrition Centre and hereby waive release and forever discharge Muscle Fury Boutique gym and Nutrition Centre from any and all responsibility or liability for injuries or damages resulting in my participation in any activities or my use of any equipment or facilities in the above mentioned activities. I realise that my participation in these activities involve the risk of injury or even death, I hereby confirm that I am voluntary engaging in a level of exercise, which has been discussed with me. I further state that I agree to my personal details disclosed for the pre exercise questionnaire being held on record at Muscle Fury Boutique gym and Nutrition Centre until such time that I request their destruction. I have read and agree to Muscle Fury Boutique gym and Nutrition Centres Terms & Conditions. Name: ____________________________ Signed: _____________________ Date: _______________

OFFICAL USE ONLY

Joining Fee Paid: DD Form Complete: 1st Month Paid: Form Signed: Membership Card: Database:

Staff Members Name:

Signature: Date Entered onto Database: