Docstoc

Exhibits

Document Sample
Exhibits Powered By Docstoc
					                                                                                                                                                      ~ TO BE COMPLETED BY STAFF ~

 MEMBERSHIP                                                                                                                            MEMBER #_______________ DATE _______________
                                                                                                                                       INSTRUCTOR: ________________________________
 AGREEMENT                                                                                                                             REFERRED BY: _______________________________


 MEMBER INFORMATION                                                              PAYMENT INFORMATION (Cash is acceptable for single class payments, only)
 Name: ___________________________________________________________________       Card Type: VISA         MasterCard  Other       Check  Cash 
 Address: _________________________________________________________________
 City: _______________________ State: _____________________ Zip: ______________  Card # ________________________________________________________________
 Phone: _______________________________ Home Location: _________________________ CVV Card Code: __________________ Exp Date: ___________________________
 Email: ___________________________________________________________________      Issuing Bank: __________________________________________________________
                                                                                 Name on Card: _________________________________________________________
 MMF MOMMY & ME CLASS FORMATS                                                    Billing Address: _________________________________________________________
      Metro Stroller Fit
                                                                                 ______________________________________________________________________
      Metro Kick Fit                                                            MEMBERSHIP & ENROLLMENT FEES
      Metro Core & More                                                         Metro Moms Fitness Membership Fee                            $_____________
      Metro Mom & Me Yoga                                                       Twelve-Month (12) Commitment Discount                        Yes        No 
      Metro Run With Me                                                         Introductory Package For New Members (select one)            $_____________
      ____________________________________                                               “Welcome Package” - $25                            $_____________
                                                                                           “Premiere Package” - $60                          $_____________
 MMF MOMMY & ME MEMBERSHIP OPTIONS (select one)                                  Other_____________________________________________           $_____________
      Metro Moms Fitness – Local (one location)              $ 50.00 / month    Sales Tax @____________% (tax on Merchandise only)           $_____________
      Metro Moms Fitness – Community (multiple locations)    $ 75.00 / month    FIRST MONTH TOTAL                                            $_____________
      Metro Moms Fitness – Saturdays                         $ 25.00 / month    TOTAL FOR RECURRING MONTHS                                   $_____________

                                   Metro Moms Fitness Local Membership entitles the member to unlimited participation in all class formats at one location.
                           Metro Moms Fitness Monthly Community membership entitles the member to unlimited participation in all class formats at all locations.


                                                         ~ MEMBERSHIP AND PAYMENT TERMS AND CONDITIONS ~
 I understand that I am purchasing a Metro Moms Fitness membership under the terms and conditions of this Agreement.
 I hereby agree to pay Metro Moms Fitness, its Licensee, or its agent (Parks and Recreation, Retail Shopping Center, Hospital, or other organization) monthly membership fees as
  indicated above to participate in the selected Metro Moms Fitness program. The agreed payment method shall be as follows: (select one)
         Cash Payment Method: Make check or money order payable to: _____________________________________________________________________.
         EFT Payment Method: I authorize Metro Moms Fitness or its Licensee or agent to initiate debit entries on my credit / debit card for either the purchase of a one-time Metro
           Membership Pass or for the purpose of my Metro Monthly Membership fees under the terms and conditions of this membership Agreement. This authority is to remain in full
           effect until Metro Moms Fitness has received written notification from me of its termination in such time and in such manner as to afford Metro Moms Fitness or its agent at least
           five business days before the next pre-authorized auto-pay date which is on the first (1st) or fifteenth (15th) day of each month, to act upon my request. Cancellation received
           after the five-day notification period will result in an additional draft prior to cancellation.
 12-month commitment discount: I understand if I elect the 12-month membership commitment to Metro Moms Fitness I will receive $10 off of each month’s dues for the first 12
  consecutive months of my membership. If I obtain one referral, I will receive a complimentary MMF apparel item (valued up to $20). If I obtain two referrals within the 12-month period,
  my 13th month will be charged as half-off. If I obtain three or more referrals within the 12-month period, each month starting at the third month will be complimentary of MMF and added
  to the months following the initial 12-month period (i.e. three referrals = 14th for free, four referrals = 15th for free, and so on). All referrals must commit to a minimum of one-month’s
  membership in order to be considered for referral credit. If I choose to cancel my membership I can do so at anytime but must pay Metro Moms Fitness $10 back for each month I
  received the discount in order to terminate my membership.
 It is mandatory for new member to purchase their choice of either the Welcome Package or Premier Package. For any member who terminates their membership or pays month-to-
  month and allows more than two (2) months to pass without activity, the member must pay $15 in order to reactive their membership.
 Failure to pay on time will result in cancellation of my membership for the upcoming month(s).
 Cancellation does not terminate my responsibility or liability for any outstanding fees or charges incurred in respect to my membership.
 I agree to inform Metro Moms Fitness or its Licensee or agent of any change in my credit/debit card information (i.e. expiration date, card number, etc.) within 5 days of the next pre-
  authorized payment.
 Monthly membership fees are not prorated. For billing purposes, the membership activation date shall be considered either the first or the fifteenth day of the month, whichever day
  falls closest to the actual sign-on date. For example, a member initiating her membership on the 10th of the month will be billed as if the membership became active on the 15th day of
  the month; monthly consecutive billings being due on the 15th of each month thereafter.
 I understand that I do not have the ability to “freeze” or “hold” my membership at any point in time, with the sole exception of being pregnant during membership. For any member who
  attends fitness classes during their pregnancy and delivers their baby while their membership is active, their membership will be considered frozen for 8 weeks. Membership payments
  will reoccur after the 8-week period unless cancellation within a five-day notification of reenactment occurs.
 I agree that membership fees including any enrollment fees are not refundable and membership may not be used by or transferred to another person.
 I understand that rates and terms are subject to change without notice.
 I acknowledge that all returned checks and or unpaid ACH drafts or dishonored pre-authorization payments will be accessed a fee of $25.00 per transaction.
 I have been advised of and acknowledge the terms and conditions of pre-authorized credit / debit card payments and my responsibilities with respect thereto. I confirm that ALL
  persons whose signatures are required to sign on the credit / debit account have signed this authorization.
 I hereby assume full responsibility for my participation in the Metro Moms Fitness class and I assume any and all risk of bodily injury, death or property damage I or my dependent may
  sustain, whether due to negligence or otherwise. I knowingly and voluntarily release, waive, discharge, covenant and agree not to sue, and to defend and hold harmless Metro Moms
  Fitness, it’s owners, instructors, employees, agents and Licensees (all hereinafter collectively called “MMF”) for, from and against any and all liability, loss, cost or damage, and any
  claim or demands therefore, including attorney’s fees, court costs and any other expense that may be incurred by MMF on account of injury to person or property, or resulting in injury
  or death, whether caused by or due to the negligence MMF or any one of them, or otherwise while I am in or upon the premises operated by MMF or any one of them, or while I am at
  another facility instructed by representative of MMF. This provision shall also bind my personal representatives, assigns, heirs and next of kin.

I, ________________________________________________________________, have read, understand and agree to the above terms and voluntarily sign this Agreement.
                Member’s name (print legibly)
Member Signature: _________________________________________________       Date:________________________________________
MEMBER MEDICAL RELEASE

Member Name: _________________________________________________                                  Date: _____________________________________

Physician’s Name: ______________________________________________                                Phone Number: _____________________________

Emergency Contact Name: ________________________________________                                Relationship: _______________________________

                                                                                                Phone Number: _____________________________

Does your physician know you are participating in this exercise program?        Circle One: YES / NO

DESCRIBE YOUR CURRENT EXERCISE PROGRAM: _________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

CHECK THE BOXES BELOW THAT PERTAIN TO YOUR HEALTH EITHER CURRENTLY OR IN THE PAST. PLEASE ADD COMMENTS TO HELP US BETTER
UNDERSTAND YOUR HEALTH BACKGROUND AND RESTRICTIONS:

        History of heart problems, chest pain or stroke           ____________________________________________________________
        Elevated blood pressure          ______________________________________________________________________________
        Any chronic illness or condition __________________________________________________________________________
        Difficulty with physical exercise __________________________________________________________________________
        Surgery in the last 12 months ___________________________________________________________________________
        Advice from physician not to exercise _____________________________________________________________________
        Pregnancy now or within the last 3 months _________________________________________________________________
        History of breathing, lung, or respiratory issues _____________________________________________________________
        Muscle, joint or back disorder, pain, or any previous injury still affecting you ______________________________________
        Diabetes or thyroid condition ____________________________________________________________________________
        History of smoking, alcohol or drugs ______________________________________________________________________
        Obesity (more than 25% over ideal weight) ________________________________________________________________
        Increased blood cholesterol _____________________________________________________________________________
        History of heart problems in immediate family ______________________________________________________________
        Hernia or any condition that maybe aggravated by lifting weights _______________________________________________

Comments: ________________________________________________________________________________________________

__________________________________________________________________________________________________________


                                              ~ AGREEMENT AND RELEASE OF LIABILITY ~
1.   In consideration of being allowed to participate in the activities and programs of Metro Moms Fitness (MMF) and to use its facilities and equipment
     in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge MMF, employees, instructors, Licensees, and all
     others (MMF representatives) from any and all responsibilities or liabilities from injuries or damages arriving out of or connected with my
     attendance at MMF classes, my participation in all activities, my use of equipment or any act of omission, including negligence by MMF
     representatives. (Initials_______)
2.   I understand and am aware that strength training, flexibility and aerobic exercise, including the use of equipment, are a potentially hazardous
     activity. I also understand that fitness activities involve a risk of injury and even death, and that I am voluntarily participating in these activities
     and using equipment and machinery with knowledge of the danger involved. I hereby agree to expressly assume and accept any and all risks of
     injury or death. (Initials ______)
3.   I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would
     prevent my participation or use in class. I do hereby acknowledge that I have been informed of the need of a physician’s approval for my
     participation in an exercise/fitness activity or in the use of exercise equipment. I also acknowledge that it has been recommended that I have a
     yearly or more frequent physical examination and consultation with my physician as to physical activity, exercise and use of exercise and training
     equipment so that I might have his/her recommendations concerning these fitness activities and equipment use. I acknowledge that I have either
     had a physical examination and been given my physician’s permission to participate, or that I have decided to participate in activities and use of
     equipment without the approval of my physician and do hereby assume all responsibility for my participation, activities and utilization of equipment
     in my activities. (Initials ______)


Member Name (Please print clearly) __________________________________________


Member Signature__________________________________________                    Date: _______________________________
                                                                                                                                                     ~ TO BE COMPLETED BY STAFF ~

PRENATAL MEMBERSHIP                                                                                                                    MEMBER #_______________ DATE _______________
                                                                                                                                       INSTRUCTOR: ________________________________
AGREEMENT                                                                                                                              REFERRED BY: _______________________________


MEMBER INFORMATION                                                              PAYMENT INFORMATION (Cash is acceptable for single class payments, only)
Name: ___________________________________________________________________       Card Type: VISA         MasterCard  Other       Check  Cash 
Address: _________________________________________________________________
City: _______________________ State: _____________________ Zip: ______________  Card # ________________________________________________________________
Phone: _______________________________ Home Location: _________________________ CVV Card Code: __________________ Exp Date: ___________________________
Email: ___________________________________________________________________      Issuing Bank: __________________________________________________________
                                                                                Name on Card: _________________________________________________________
METRO MOMS FITNESS PRENATAL CLASS FORMATS                                       Billing Address: _________________________________________________________
     Metro Yoga Mama
                                                                                ______________________________________________________________________
     Metro Fit Mama                                                            MEMBERSHIP & ENROLLMENT FEES
     Metro Prenatal Other                                                      Metro Moms Fitness Membership Fee                            $_____________
     Metro Prenatal Personal Training                                          Introductory Package For New Members (Optional)              $_____________
     ____________________________________                                                “Welcome Package” - $25                           $_____________
                                                                                          “Premiere Package” - $60                          $_____________
                                                                                Other_____________________________________________           $_____________
METRO MOMS PRENATAL MEMBERSHIP OPTIONS (select one)                             Other_____________________________________________           $_____________
     Metro Moms Fitness Prenatal Special (6-class pass) $ 45.00 / 6 class pass Sales Tax @_________% (tax on Merchandise only)              $_____________
     Metro Moms Fitness Prenatal Unlimited Monthly      $ 60.00 / month        FIRST MONTH TOTAL                                            $_____________
     Metro Moms Fitness Prenatal Personal Training      $ Varies per hour      TOTAL FOR RECURRING MONTHS                                   $_____________

                                    Metro Moms Fitness Prenatal Special Membership entitles the member to sic (6) prenatal classes at one location.
                   Metro Moms Fitness Prenatal Unlimited Monthly Membership entitles the member to unlimited participation in classes for one month at one location.


                                                        ~ MEMBERSHIP AND PAYMENT TERMS AND CONDITIONS ~

 I understand that I am purchasing a Metro Moms Fitness membership under the terms and conditions of this Agreement.
 I hereby agree to pay Metro Moms Fitness, its Licensee, or agent (Parks and Recreation, Retail Shopping Center, Hospital, or other organization) monthly membership fees as
  indicated above to participate in the selected Metro Moms Fitness program. The agreed payment method shall be as follows: (select one)
        Cash Payment Method: Make check or money order payable to: ____________________________________________________________________________________.
        EFT Payment Method: I authorize Metro Moms Fitness, its Licensee, or its agent to initiate debit entries on my credit / debit card for either the purchase of a one-time Metro
             Membership Pass or for the purpose of my Metro Monthly Membership fees under the terms and conditions of this membership Agreement. This authority is to remain in full
             effect until Metro Moms Fitness has received written notification from me of its termination in such time and in such manner as to afford Metro Moms Fitness or its agent at
             least five business days before the next pre-authorized auto-pay date which is on the __________ day of each month, to act upon my request. Cancellation received after
             the five-day notification period will result in an additional draft prior to cancellation.
 Failure to pay on time will result in cancellation of my membership for the upcoming month(s).
 Cancellation does not terminate my responsibility or liability for any outstanding fees or charges incurred in respect to my membership.
 I agree to inform Metro Moms Fitness, its Licensee, or its agent of any change in my credit/debit card information (i.e. expiration date, card number, etc.) within 5 days of the next pre-
  authorized payment.
 Monthly membership fees are not prorated. For billing purposes, the membership activation date shall be considered either the first or the fifteenth day of the month, whichever day
  falls closest to the actual sign-on date. For example, a member initiating her membership on the 10th of the month will be billed as if the membership became active on the 15th day of
  the month; monthly consecutive billings being due on the 15th of each month thereafter.
 I understand that I do not have the ability to “freeze” or “hold” my membership at any point in time.
 I agree that membership fees including any enrollment fees are not refundable and membership may not be used by or transferred to another person.
 I understand that rates and terms are subject to change without notice.
 I acknowledge that all returned checks and or unpaid ACH drafts or dishonored pre-authorization payments will be accessed a fee of $25.00 per transaction.
 I have been advised of and acknowledge the terms and conditions of pre-authorized credit / debit card payments and my responsibilities with respect thereto. I confirm that ALL
  persons whose signatures are required to sign on the credit / debit account have signed this authorization.
 I hereby assume full responsibility for my participation in the Metro Moms Fitness class and I assume any and all risk of bodily injury, death or property damage I or my dependent
  may sustain, whether due to negligence or otherwise. I knowingly and voluntarily release, waive, discharge, covenant and agree not to sue, and to defend and hold harmless Metro
  Moms Fitness, it’s owners, instructors, agents, Licensees, and employees (all hereinafter collectively called “MMF”) for, from and against any and all liability, loss, cost or damage,
  and any claim or demands therefore, including attorney’s fees, court costs and any other expense that may be incurred by MMF on account of injury to person or property, or resulting
  in injury or death, whether caused by or due to the negligence MMF or any one of them, or otherwise while I am in or upon the premises operated by MMF or any one of them, or
  while I am at another facility instructed by representative of MMF. This provision shall also bind my personal representatives, assigns, heirs and next of kin.


I, _________________________________________________________________, have read, understand and agree to the above terms and voluntarily sign this Agreement.
                Member’s name (print legibly)


Member Signature: _________________________________________________                       Date:________________________________________
PRENATAL MEMBER & PHYSICIAN RELEASE

I request enrollment in Metro Moms Fitness prenatal exercise classes. I certify that I have given my treating physician the written information about
this class and have obtained the approval of my treating physician to participate. I understand that I will not be able to enroll or to continue in this
class without written permission of my treating physician. I agree to keep my physician informed of the effects of this class on my body. I further
understand that there is no requirement to perform all the class exercises and that I can withdraw from this class at any time.

During class I agree to limit my activity to that which is comfortable for me and to stop all activity if I feel uncomfortable. Upon experiencing any
discomfort at any time either during or after this class, I will immediately contact my treating physician to inform him/her and seek medical advice. I
understand that all forms of exercise involve some risk of injury. I accept complete responsibility for my health and well-being and that of my unborn
child in my voluntary participation in this program. In consideration of my participation in the Metro Moms Fitness program, I, for myself, my personal
representative, assigns, and heirs hereby knowingly and voluntarily release, waive, discharge, and hold harmless Metro Moms Fitness, it’s owners,
instructors, Licensees, agents and employees (hereinafter collectively called “MMF”) for, from, and against any and all liability, loss, claims or demands
incurred on account of injury or death to person or property, known or unknown, whether caused by or due to the negligence of MMF.

Information relating to my health status will be treated as confidential and will not be released to any person other than program staff without consent.

Participant Name: __________________________________________________ Phone: ____________________________

Participant Signature: __________________________________________ Email: _______________________________________



PARTICIPANT PRE-EXERCISE HEALTH ASSESSMENT:
 Part 1: Status of Current Pregnancy                                                     Part 2: General Health Status
 Due Date: ___________________________________                                           Your Age: ____________
 During this pregnancy, have you experienced:                        Yes     No          In the past, have you experienced:                    Yes    No
   Fatigue?                                                                                Miscarriage in an earlier pregnancy?                    
   Bleeding?                                                                               Other pregnancy complications?                          
   Unexplained abdominal pain?                                              
   Sudden swelling of the ankles, hands, feet, or face?                                Please state number of previous pregnancies:________
   Constant headaches?                                                                 _____________________
 If you answered yes to any of the questions in Part 1 or Part 2, please explain in detail: _________________________________

 _______________________________________________________________________________________________________


 _________________________________________________________                                ___________________________________________
 Participant’s Signature                                                                  Date



  PHYSICIAN CERTIFICATION:
  A approve of my patient’s participation in this class. The health status of this patient will permit her to participate in the Metro Moms Fitness
  prenatal program subject to restrictions listed below. (List any precautions or indicate exercises that this patient should not perform):

  ________________________________________________________________________________________________
  ____________________________________________________________________
  This certification may be modified or revoked by me at any time, in writing or by contacting Metro Moms Fitness directly, should my patient’s health
  status change.

  _________________________________________________________                                _______________________________________
   Signature of Treating Physician                                                          Date


  ________________________________________________________                                 _______________________________________
   Physician’s Printed Name                                                                 Physician’s Office Telephone




              Thank you for supporting your patient’s desire to engage in Metro Moms Fitness prenatal classes.
                      If you have any questions or would like further information about our program,
                            please contact us at 817-707-5007 or info@metromomsfitness.com.

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:5
posted:8/2/2011
language:English
pages:4