Membership Sign Up Form

Name*

First Last

Address*

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

Email*

Enter Email Confirm Email

Best Contact Phone*

Work Phone

Employer*

Date Of Birth*

Emergency Contact Name*

First Last

Emergency Phone #*

Relationship

Membership Options:*

Monthly Rate ($30 +enrollment fee + FIF Fee)

Please check the box for the gym membership you interested in purchasing. Once you submit this form our staff will contact you for payment. * Please see above section titled "Rules of Enrollment" for details on rules of memberships. ** Please see above for details on enrollment fees.

Please leaves NAMES AND AGES of each family member who will be enrolled:

Please leave Comments/Notes here:

Buyers Right To Cancel*

I agree to these terms

If you wish to cancel this contract, you may cancel by providing written notice by certified or registered mail to Orofino Physical Therapy & Wellness, P.O. Box 2546, Orofino, ID 83544. This notice must say that you do not wish to be bound by this contract and must be postmarked within three business days from the date on this agreement. The processing fee paid at the time of enrollment is nonrefundable even if cancelled within the authorized three business days. If three day right to cancel is executed, reimbursement of the initial amount paid (minus the processing fee) will be made within 30 days of postmarked date of notice by check or credit card reversal.

EFT & Facility Improvement Fee (FIF) Authorization*

* I understand and agree to the annual EFT & Facility Improvement Fee(FIF) as noted above

Member agrees to pay a Facility Improvement Fee of $35 upon sign up and every year annually as a condition of being a member. The annual Facility Improvement Fee is drafted annually according to the month you are enrolling.

Acknowledgment of Responsibility*

I agree to these terms

You acknowledge and agree that non-members are not allowed within any Orofino Physical Therapy & Wellness Facility outside of staffed hours (Mon-Fri 8 am to 5 pm), If you are discovered bringing in or allowing a non-member access to any Orofino Physical Therapy & Welness Facility outside of those staffed hours you agree to pay a $50 fine per incident. You further agree that $50 fine may be deducted from the account you have on file as your billing method within 7 days of incident. Being issued a fine is not a release of contract and in no way releases you from the above term of this agreement. Lastly, you understand that after 3 incidents of being issued a fine that you may be banned from the property of all Orofino Physical Therapy & Wellness Facilities. Being banned does not release you from your contract obligations listed above.

Acknowledgment of Responsibility*

DO NOT CHECK THIS box until you have read the applicable sections listed on this page. Each Member is entitled to a completely filled in copy of this agreement.

The undersigned acknowledges that the use of equipment, food and nutritional products and services involves an inherent risk of personal injury. The undersigned agrees to assume all risks of personal injury to the undersigned, his or her spouse, children, other family members, guests or invitees waives any and all claims that the undersigned may have against Orofino Physical Therapy & Wellness or any of its agents or successors and assigns (a Orofino Physical Therapy & Wellness Party) for any such personal injury (and no Orofino Physical Therapy & Wellness Party shall be liable to the undersigned or his or her spouse, children, unborn children, and other family members, guests or invitees for any such personal injury) including without limitation (i) injuries arising from the use of any exercise equipment or machines (ii) injuries arising from participation in supervised or unsupervised activities and programs in exercise rooms, shower rooms, weight rooms, or other areas of any Orofino Physical Therapy & Wellness facilities, (iii) injuries or medical disorders resulting from exercising at any Orofino Physical Therapy & Wellness facilities including heart attack, strokes, heat stress, sprains, strains broken bones, and torn or damaged muscles, ligaments or tendons or (iv) accidental injuries within any Orofino Physical Therapy & Wellness facilities, including locker rooms, dressing rooms, office workout or cardio area. No Orofino Physical Therapy * Wellness Party shall be liable with respect to any personal property that is damaged, lost or stolen while on or around Orofino Physical Therapy & Wellness facilities premises including, but not limited to a vehicle or its contents or any property left in a locker room or on your person.

Name Of MEMBER WHO AGREES TO THESE TERMS*

First Last

Date*

Name Of PARENT OR GAURDIAN Who agrees to these terms:

First Last

You Must Enter A Name Here if You Are Signing Up For A Member Who Is Under 18 Years Old.

Date

Membership Sign Up Form

Membership Sign-Up