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Please print the following form, fill out all required fields and bring into the Workout Center

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WAIVER OF LIABILITY, RELEASE AND ACKNOWLEDGMENT OF RISK, AND HEALTH HISTORY

In consideration of the services of Braneri Systems, Ltd. And The Workout Center, their agents, owners, officers, volunteers, participants, employees and all other persons acting in any capacity on their behalf, along with the owner or owners of the premises in which the Workout Center is located, their heirs, personal representatives and assigns, (herein collectively referred to as the “Released Parties”), I hereby agree to release and discharge the Released Parties, on behalf of myself, my children, my heirs, my assigns, personal representatives and all other persons acting on my behalf, in any capacity, as follows:

I acknowledge that use of the Workout Center and/or the equipment of Braneri Systems, Ltd. involves physical exercise, sport and recreational activities that may cause injury. I understand that there is an inherent risk of injury when choosing to participate in any physical exercise, sport, wellness, and/or recreational activities. My use of the Workout Center and/or Braneri Systems equipment is a voluntary activity in all respects and I assume all risks of injury and illness that may result from such use, whether such use is for group activities or individual use.

I fully discharge and release the Released Parties from any and all liability, claims and causes of action from injuries or illness (including death), damages or loss which I may have or which may accrue to me on account of my participation in all activities utilizing the facility.

I further agree to indemnify and hold harmless and defend the Released Parties from any and all claims resulting from injuries or illness, damages or loss, including attorney fees, sustained by me arising out of or in connection with or in any way associated with my use of the Workout Center or equipment owned by Braneri Systems, Ltd.

I acknowledge that I have been advised to consult with my physician before I undertake any physical activity or exercise program. I certify that I am in good health and sufficient physical condition to properly use the Workout Center and any of the equipment located within the Workout Center and/or owned by Braneri Systems, Ltd.

I further acknowledge that the Released Parties are neither responsible for nor liable for any loss of or theft of any personal property brought to or left at the Workout Center and I hereby release the Released Parties from any liability for such loss or theft.

Name : _____________________________________________________________________

Address : ___________________________________________________________________

Phone : ____________________________________________________________________

Sex : __________ Date of Birth : __________/_____/________

Physician’s Name : ___________________________________________________________

Physician’s Telephone : ________________________________________________________

Preferred Hospital : __________________________________________________________

Friend or Relative:______________________________Phone Number:_________________

Does your Physician know you are participating in an exercise class or weight training program?
Yes____
No ____

Are you pregnant? ___________
Yes____
No ____

Are you currently taking any medications?
Yes____
No ____

If yes please list below:

_________________________________________________________________________

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HEALTH HISTORY

Do you now or have you had with in the past year:

  Yes No
High Blood Pressure? _______ _______
History of heart problems? _______ _______
History of heart problems in immediate family? _______ _______
Angina? _______ _______
Difficulty with physical exercise? _______ _______
Advice from physician not to exercise? _______ _______
A chronic illness? _______ _______
Muscle ,joint or back disorder? _______ _______
Surgery within last few months? _______ _______
History of lung problems? _______ _______
Diabetes? _______ _______
Do you smoke? _______ _______
Are you under stress (work/family)? _______ _______


I acknowledge that I have read and fully understand this Waiver of Liability and Release as set forth above and that I am signing it voluntarily.

Printed Name: ___________________________________

Signature : ______________________________________

Date: __________/______/__________

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GYM POLICY

Once membership fees are paid, they will run continuously until the due date.

NO REFUNDS. NO PAYMENT PLANS.

In order for the Workout Center to better service our membership we would like you to take the time to answer the questions below.

  Yes No
May we e-mail you to better provide information to you? (specials, new classes, events, etc...) _______ _______
Email Address : _________________________________________________________    
May we contact you through phone or text message? _______ _______
If yes, list cell number : ( _______ ) ______-________    
What was your original due date? ________/_____/________    
Last renewal date? ________/____/________    
Do you have any specific fitness or athletic goals? _______ _______
If yes, please list below :    

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