Personal Details - The Shrewsbury and Telford Hospital NHS Trust by dandanhuanghuang

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									                       Staff Fitness Centre Membership form
                                     PRH Centre
Please complete the details below and return to the HR Department, PRH.



Personal Details


Surname …………………………………………….                         First Name …………………………………………...

Sex m/f               Date of birth :………./…………/…………

Home address: …………………………………………………………………………………………………...

……………………………………………………………………………………………………………………...

Telephone no (home) ……………………                Department …………………. Ext. No. …………………….

Designation ………………………………………                        Personal No …………………………………………




Medical Questionnaire

Please answer all the questions:
1. Has your doctor ever said that you have heart disease, high blood pressure or any     Yes/No
   cardio-vascular problems?
2. Do you ever have pains in your chest, or feel breathless at rest?                     Yes/No
3. Do you frequently get headaches                                                       Yes/No
4. Do you ever feel faint or dizzy on exertion?                                          Yes/No
5. Do you suffer from either pain or limited movement in your back or any joints which   Yes/No
   may be aggravated by exercise?
5. Do you have any other medical condition which may affect your ability to              Yes/No
   participated in exercise e.g. diabetes, epilepsy, pregnancy etc?

……………………………………………………………………………………………………………………...

……………………………………………………………………………………………………………………...

If you have ticked yes to any of the above questions, or have any doubts about your current
health, please consult your doctor before you continue with your gym membership
Please note that whilst the induction session will provide advice on exercise and the correct use of
equipment, not a medical assessment.
Rules of Membership
1.  All members must be over 18 years of age.
2.  Attendance at fitness centre induction prior to being accepted for membership.
3.  Members will behave with courtesy and consideration towards other fitness centre users.
4.  Members are responsible for leaving the fitness centre clean and tidy after use.
5.  The exercise equipment should be used only in accordance with the instructions given.
6.  Only plimsolls or training shoes should be worn in the exercise area.
7.  Only plastic drinks containers should be taken into the exercise area.
8.  Members are responsible for reporting any faulty or damaged equipment to the engineers as soon
    as they become aware of it.
9. Members must not loan their membership card to any other person.
10. Lost or stolen membership cards must be reported to the HR Department within 24 hours.
    Replacement cards will be issued at a cost of £1.50.
11. Members who disregard the rules may be barred from using the fitness centre facilities or
    disqualified from membership.

Declaration
 I have read and understood the rules of membership and agree to abide by them.

 I authorise the Pay Services Department to deduct an initial £12 for the joining fee (to include gym
  induction and swipe card) and £12 to cover the first months membership from my next salary (this
  amount will be pro-rata’d for members joining after the 1st day of the month) after my membership
  start date and thereafter, £12 per month from my salary until further notice.

 I will confirm in writing to the HR Department, my intention to cancel my membership, giving one
  months notice.

 I confirm that I have received training in the use of the fitness centre equipment and feel
  competent to use the facilities safety.

 I understand that the Shrewsbury and Telford Hospital NHS Trust will not accept liability for any
  loss or damage howsoever caused other than through the negligence of the Trust.

Signature: ………………………………………                          Date: ………………………………………………….

I confirm that the above person has received instruction in the use of all equipment currently in the
fitness centre.

Name of Instructor (please print) ……………………………………………………………………………….

Signature: ………………………………………                          Date: ………………………………………………….
             (Fitness Instructor)

 Please return this form to the HR Department, House 2, Drs Residences, PRH. You will then be
   contacted to book an induction.
For office use only

Induction date        ………………                Salary deduction actioned

Training completed

Membership start date: …………………..            Card No. ……………………………

								
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