Submit Fitness Center Registration - The Beech Mountain Club

Member Name:

Membership Number:

Your email address:*

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor:

YesNo

Do you feel pain in your chest when you do physical activity:

YesNo

In the past month, have you had chest pain when you were not doing physical activity:

YesNo

Do you lose your balance because of dizziness or do you ever lose consciousness:

YesNo

Do you have a bone or joint problem that could be made worse by a change in your physical activity:

YesNo

Is your doctor currently prescribing drugs for your blood pressure or heart condition? If yes, please list your medications in the box below.:

YesNo

List of medications (if the answer to the above is YES):

Do you know of any other reason why you should not do physical activity? If yes, state reason(s):

YesNo

List reasons (if the answer to the above question is YES) :

I attest that I have completed the PAR-Q form above to the best of my knowledge and, further, I agree that I have read and accept the Agreement and Release of Liability Statement below.:

Fitness Center Registration Please complete this form to submit your Fitness Center Registration. By clicking the "submit" button below, you are confirming that you have read, accept and agree to the Agreement and Release of Liability (below), and that you agree to uphold the following rules: Swipe cards are personal and confidential and cannot be shared. No one is permitted to accompany the fitness member without proper payment and access approval. Penalty for failure to uphold access rules: Forfeiture of fitness membership/access fees. Suspension of Wellness/Fitness Center access for one year. Access is monitored by video camera and recorded for verification. If you are the last one leaving the Fitness Center, please turn off all lights, fans and/or televisions and make certain the door is closed/locked.
Member Name:
Membership Number:
Your email address:*
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor:	YesNo
Do you feel pain in your chest when you do physical activity:	YesNo
In the past month, have you had chest pain when you were not doing physical activity:	YesNo
Do you lose your balance because of dizziness or do you ever lose consciousness:	YesNo
Do you have a bone or joint problem that could be made worse by a change in your physical activity:	YesNo
Is your doctor currently prescribing drugs for your blood pressure or heart condition? If yes, please list your medications in the box below.:	YesNo
List of medications (if the answer to the above is YES):
Do you know of any other reason why you should not do physical activity? If yes, state reason(s):	YesNo
List reasons (if the answer to the above question is YES) :
If you answered YES to one or more of the above questions, talk to your doctor BEFORE you participate in activities at the Fitness Center. Tell your doctor about the PAR-Q and which questions you answered YES to. YOU MUST HAVE YOUR DOCTOR SIGN A PHYSICIAN’S CLEARANCE FORM BEFORE YOU CAN WORK OUT IN THE FITNESS CENTER. You may download a copy of the Physician’s Authorization Form here. If you answered NO to all questions, you can be reasonably sure that you can start becoming more physically active – begin slowly and build up gradually. This PAR-Q Form becomes invalid if your condition changes so that you would answer "Yes" to any of the questions above.
I attest that I have completed the PAR-Q form above to the best of my knowledge and, further, I agree that I have read and accept the Agreement and Release of Liability Statement below.:
AGREEMENT and RELEASE OF LIABILITY In consideration of being provided access to or being permitted to participate in the Beech Mountain Club Fitness Center and to use its facilities, equipment and machinery, in addition to the payment of any fee or charge, I hereby waive, release and forever discharge the Beech Mountain Club and its officers, agents, employees, representatives, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in any activities or my use of equipment or machinery in the above mentioned facilities. I understand and am aware that strength, flexibility, and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also understand that fitness activities involve risk of injury and even death and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death. 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 in any of the activities and programs of the BMC Fitness Center or use of equipment or machinery. I do hereby acknowledge that I have been informed of the need for a physician’s approval for my participation in exercise/fitness activity or in the use of exercise equipment and machinery. 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 have recommendations concerning these fitness activities and equipment use. I acknowledge that I have either had a physical examination and have been given my physician’s permission to participate, or that I have decided to participate in activity and/or use of equipment and machinery without the approval of my physician and do hereby assume all responsibility for my participation in activities and utilization of equipment and machinery during my activities.

Fitness Center Registration

AGREEMENT and RELEASE OF LIABILITY