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 choose your payment method:
(More details are listed below about each option)
I hereby authorize Orofino Physical Therapy & Wellness or its' agent to charge the amount indicated above (Membership Options Section); to the credit card provided below.
I hereby authorize Orofino Physical Therapy & Wellness or its' agent to charge the amount indicated above (Membership Options Section); to the credit card provided below; once per month. I also understand that immediately following the initial term of the agreement my dues will continue every month on a month by month basis until Orofino Physical Therapy and Wellness is served with a written request for cancellation. All written requests to cancel must take effect no sooner than 30 days from when the written request was postmarked. I further understand that if I am submitting my cancellation prior to the date indicated in the "Initial Term Ends" portion of this agreement that my cancellation will not be processed until that date. A cancellation form may be picked up at the location of your choice. Paid in Full memberships will be renewed automatically by Credit Card Charge at the end of the initial term, for the same amount and same period, unless canceled in writing 30 days prior to "Initial Term Ends" date.
If you chose the Credit Card Payment Method Above.... Please List Your Name As It Appears On Credit Card
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.
Member agrees to pay an annual Facility Improvement Fee of $35.00 every year that they are a member as a condition of being a member. The annual Facility Improvement Fee is drafted according to the month you are enrolling on the following basis:
Enrollment in Jan-Feb-Mar = Fee due on April 1st;
Enrollment in April-May-June = Fee due on July 1st;
Enrollment in July-August-September= Fee Due on Oct 1st;
Enrollment in Oct-Nov-Dec = Fee due on Oct. 1st;
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.
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.
You Must Enter A Name Here if You Are Signing Up For A Member Who Is Under 18 Years Old.