Platinum Memberships | Nick Hose Fitness

Full Name*

Age*

Date of birth*

DD

MM

YYYY

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone

Mobile Phone*

Emergency Contact Person*

Emergency Contact Person's Number*

Membership Type*

If paying weekly or monthly

BSB

Account Number

Bank

Card Type

Card Expiry

1. Do you have, or have you had:*

Please specify details here

2. Have you ever been told you are at risk of...?*

Please specify details here

3. Have you ever been told that you have heart problems, eg.*

Please specify details here

4. Do you have, or have you experienced...?*

Please specify details here

5. Do you experience sudden shortness of breath?*

Yes
No

6. Have you ever had a pain or pressure, either at rest or during exercise?*

In the middle of, or on the left side of, the chest
In the neck region
At the left shoulder or down the left arm
None of the above

Please specify details here

7. Do you take any medications for (please specify below)*

Please specify details here

8. Are you aged over 60 years of age?*

Yes
No

9. Do you have any joint or muscular problems that may affect your ability to train?*

Yes
No

10. Do you have any other conditions or injuries that may affect your ability to train?*

Yes
No

Please specify details here

Today's Date*

I agree that all information provided above is true and accurate*

Yes, I agree

Release and Waiver of Liability Form (Please Read)

Upon checking in at the NICK HOSE FITNESS Residence, all residents are required to sign the Fitness Center Release and Waiver of Liability Form below. Should you have any questions regarding this or any other items, please do not hesitate to contact us. Health Statement: In requesting permission to access or use the equipment of the NICK HOSE FITNESS facility, I affirm that my general health is good and that I am not adversely affected by the exercise I will undertake. I further affirm that I am able to perform exercise of a vigorous nature. I am not currently under the care of a physician who should be advised of my desire to participate in this physical activity. If I am under the care of a physician, I affirmatively state that I have received his/her permission to participate in vigorous exercise at the NICK HOSE FITNESS Center. AGREEMENT TO FOLLOW RULES AND POLICIES: I agree to follow all rules and policies of the NICK HOSE FITNESS facility and to abide by any reasonable request concerning use of the facility directed to me by the staff of NICK HOSE FITNESS. I agree to operate and use the equipment only in the manner in which it was designed and intended to be used. I understand that my failure to abide by and to follow instructions or request may result in the termination of my privileges of using the facility. I further understand that NICK HOSE FITNESS has the right to terminate or alter my privileges at the NICK HOSE FITNESS facility at its complete and unilateral discretion. RELEASE AND WAIVER: In consideration of my access to the NICK HOSE FITNESS facility I hereby accept all risks to my health and of my injury or death that may result from such participation and I hereby release of the Office of NICK HOSE FITNESS and its employees and representatives from any liability to me, my personal representatives, estate, heir, next of kin and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may to result from or occur during my use of the facilities, whether caused by negligence of the company, employees, or representatives or otherwise. I agree to release and hold harmless NICK HOSE FITNESS and its employees from any and all liability whatsoever which may result from my use if the facility or equipment.

AGREEMENT TO FOLLOW RULES AND POLICIES AS ABOVE*

Yes, I agree

I have carefully read this agreement and understand it to be a release and waver of all claims and causes of action for my injury or death or damage to my property that occurs while using the NICK HOSE FITNESS facility and it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligence or intentional act of omission.

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Memberships

MEMBERSHIP

1 Year

Gold Membership

6 Month

Silver Membership

3 Month

Bronze Membership

Casual Membership: $10 per visit

Membership and Medical Info

Release and Waiver of Liability Form (Please Read)