How To Get A Membership At Angelina Rehabilitation Center
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- Gabriel Washington
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1 APPLICATION FOR MEMBERSHIP.. Member Information Referring Physician Name:,, (Last) (First) (Middle) Driver s License #: Sex: M /F: Date of Birth: Social Security #: Address: Home Address: City: State: Zip: Home Phone: ( ) - Cell #: ( ) - I understand my membership is in effect (whether I attend or not), and I am responsible for any unpaid balance through the date of termination of my 24_( ) /12 ( ) month agreement. The imitation fee and membership fees paid are non refundable (whether I attend or not). Signature: Date:... For Office Use Only Type ( ) Indoor Wellness Program ( ) 12 Month Agreement ($40.00/Month/non-refundable) ( ) Indoor/Pool Wellness Program ( ) 24 Month Agreement ($35.00/Month/non-refundable) The date your membership begins:. The amount of your initiation fee = $50.00/non-refundable Deposit for access card: $ (Refundable when card is returned in good condition) Staff Initials Date Comments:
2 MEDICAL PROFILE Name: Age: Sex: Primary Physician: Phone #: In case of emergency contact at Phone # Relationship to contact: PAST MEDICAL HISTORY Rheumatic Fever Varicose Veins Injuries: Heart Trouble: Heart Murmur Lung Disease Back Coronary Heart Disease High Blood Cholesterol Diabetes Knees Myocardial Infarction High Blood Pressure Arthritis Ankles Rhythm Abnormalities Stroke Asthma Neck History in Family Overweight Advise from Physician not to exercise (20 lbs or more) Other (explain: PRESENT SYMPTOMS Check the appropriate box if you have recently experienced any of the following: [ ] Chest Pain [ ] Heart Palpitations [ ] Cough on Exertion [ ] Back Pain [ ] Lightheadedness [ ] Shortness of Breath If you have had a recent operation please explain what type and how recent: RISK FACTORS 1. Do you smoke? Yes No Quit ( Cigarettes Cigars Pipe) 2. Are you presently taking any medications? Yes No If yes, please list the medication and reason for taking: 3. Have you ever had a stress test (graded exercise E. K.G.)? Yes No Would you be interested in one? Yes No
3 RELEASE OF LIABILITY Release of Liability Statement for Use of Exercise Equipment I,, hereby release Angelina Rehabilitation Center from all liability associated with the use of any and all exercise equipment owned by Angelina Rehabilitation Center regardless of location. I acknowledge that I will operate said equipment in a safe manner following the manufacturer s recommendation for use and notify the Angelina Rehabilitation Center staff of any equipment malfunctions which occur while I am using it. Further more, I acknowledge that I have a personal exercise program that does not require the staff involvement. I further acknowledge that my utilization of the exercise equipment will be on a space and time available basis so to not interfere with Angelina Rehabilitation Center program Signature of Patient/Guardian Date Signature of Witness Print Name of Patient/Guardian Print Name of Witness
4 AGREEMENT 12/24-Month Addendum Agreement 1. This membership (see attached Contract) is for a minimum of [] (12) months $40.00 (initial) [] (24) months $35.00 (initial) $50.00 application fee one time fee After which the membership becomes a month to month, requiring a minimum of thirty (30) days written cancellation. (initial) 2. Non-use of client does not negate monthly payments. The twelve (12) or Twenty four (24) month period is over and above any non-pay period which may or may not be a part of this agreement, (initial) 3. Membership may be terminated on or before the first of the twelfth (12 th ) or twenty fourth (24 th ) paying month of this agreement by delivering a thirty (30) day written notice to Angelina Rehabilitation Center. No verbal termination will be acceptable; it must be put in writing and either hand delivered or mailed within the specified time limit. In the event notice is delivered, the initial Contract shall continue on a month to month basis and all other terms and conditions of the initial Contract shall remain in full force and effect. (initial) 4. If membership is payroll deducted, this contract will be in effect even if I am no longer employed at the company where the payroll deduct originated. I will be billed at home or bank drafted for the duration of this contract. (initial) I completely understand the duration of this contract. I must pay for twelve (12) or twenty four (24) months as indicated above of the initial Contract and the Termination Policy and will abide accordingly. I also understand that should I decide to cancel this contract early, there is a buy out fee of $15 per month remaining on the contract. Member Signature: Staff Date
5 RECURRING PAYMENT AUTHORIZATION FORM ACH DEBIT/BANK DRAFT If you would like to enjoy the convenience of automatic recurring billing, simply complete the bank Information section below and sign the form. All requested information is required. Upon approval, we will automatically debit your bank account for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us. Customer Information: Customer/Company Contact Name Account Number Address Phone ( ) - Ext: Payment Information I authorize angelina rehabilitation center to automatically debit my bank account listed below as specified Product/Service Description Recurring Amount Frequency Once Daily Weekly Twice/Month Monthly Quarterly (Check one) Start on / / End on: / / Month Day Year (Check one) Month Day Year No End Date Bank Information (To be completed by Customer) Bank Institution Name: Bank Routing # Bank Account # Type of Account Checking Savings. Notify me via when my Credit card is charged. (Make sure address above is correct.) Please attach avoided check for account for verification purposes Customer s signature Date
6 RECURRING PAYMENT AUTHORIZATION FORM CREDIT CARD If you would like to enjoy the convenience of automatic recurring billing, simply complete the Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us. Customer Information: Customer/Company Contact Name Account Number Address Phone ( ) - Ext: Payment Information I authorize to automatically bill the card listed below as specified Product/Service Description Recurring Amount Frequency Once Daily Weekly Twice/Month Monthly Quarterly (Check one) Start on / / End on: / / Month Day Year (Check one) Month Day Year No End Date Credit Card Information (To be completed by Customer) Card type Master Card Visa Discover Amex other Cardholder Name Cardholder ZIP Code (As shown on card) (From credit card billing address) Card Number Expires / Notify me via when my Credit Card is charged. (Make sure address above is correct.) Customer s signature Date
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Make The Switch Moving to Western Bank is Easy. Moving from one bank to another can be intimidating. That s why we have our Switch Kit. In this kit you will find simple, step-by-step instructions for moving
1 MEMBER INFORMATION Policy No. MZ0909533H0000A
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