Fitness Center Membership

Transcription

1 Fitness Center Membership (Check One) RENEWING: NEW: You are new if: 1. You have not been a fitness center member before, OR 2. You have been a member in the past, but your membership has lapsed. Please check renewing ONLY, if your membership is still current Date: Name: SEBA No: Badge No: Phone Ext: Division: Credit Card Billing Address: Address: The following information is to be completed by SEBA Personnel Payment type and amount (amount indicated below, plus enrollment fee of $18): Credit card (recurring monthly or single year): VISA, MC or Discover (Am.Ex. accepted only for single year): $ OR: Check (single year only): $ Check Total = $150 (individual) or $270 (family) plus $125 (for each additional family member) Database Add to Seba-Fit Badge Access Confirm Page 1 of 7

2 New and lapsed members are charged a non-refundable $18 enrollment fee. This additional charge is to cover the cost of adding records to the database, adding the badge to the security access list, and adding the address to the appropriate lists. Please indicate appropriate number for membership plan below: $12.50 per month for individual (recurring monthly payment) OR $ per year $22.50 per month for family * (recurring monthly) OR $ per year PLUS: $10.42 for each additional family member (recurring monthly) OR $ per year * - Family includes: SEBA member and one additional family member Credit Card Authorization & Termination of Membership Information: I authorize SEBA to charge my credit card monthly (on a recurring basis), until a cancellation form is submitted. Upon submission of the cancellation form, your membership will terminate immediately. Cancellation forms must be received at minimum of seven (7) business days prior to your next billing date, to avoid the monthly charge. Signature Print Name Changes in membership fees: Membership fees are subject to change by vote of the SEBA Board. In the event of a change, members will be notified by , and postings in the fitness center. Those who do not wish to continue their membership will need to submit a cancellation form (in accordance with the termination of membership paragraph). Initial Page 2 of 7

3 Credit card Information: You have the option of submitting this credit card information on the form below, or providing your credit card in person. (Note: direct credit card processing is possible only if a staff member is available.) Type: Visa, Mastercard, or Discover (American Express only for single year) Name as it appears on card: Expiration Date: Billing Address: Phone number: Note: This sheet will be shredded after the information is entered into Virtual Terminal. Page 3 of 7

4 Emergency Contact: Name: Phone: Work Contact (supervisor): Name: Phone: If you are applying for a Family Plan, and the family member is also a NIST employee, please provide the family member s information below: SEBA No#: Phone Ext: Division: Badge No#: Mail STOP: Address: Page 4 of 7

5 SEBA Sports & Fitness AGREEMENT I agree to abide by all the rules and regulations that govern the SEBA Fitness Center. I agree that I will use only exercise equipment and I am physically fit to operate and will use the equipment in a safe and proper manner. I also realize that neither NIST nor SEBA nor any of their staff are liable for any personal harm or injury that may occur to me as a result of improper use of the facilities or equipment or for injuries that may be sustained as a result of ill health or preexisting physical defect. I understand, too, that NIST & SEBA are not responsible for articles lost or stolen in the facility. RELEASE OF LIABILITY In consideration of being allowed to participate in the activities and programs of SEBA and to use the facilities and equipment provided by SEBA, I do hereby waive, release and forever discharge NIST and SEBA officers, employees, representatives, and all others from any and all responsibility or liability for injuries or damages incurred while participating in any SEBAsponsored sports and/or exercise activity, whether in or off the NIST grounds. I understand that participation in SEBA sports activities and the use of the SEBA Exercise Facility, hereafter referred to as SEBA Programs, is potentially hazardous. I also understand that sports and exercise activities involve a risk of injury and even death and that I am voluntarily participating in SEBA Programs and using the facilities and equipment with the knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death, regardless of age, pregnancy, or medical condition. I hereby acknowledge that I have been advised to seek advice from a physician regarding my participation in SEBA Programs. I also acknowledge that it has been recommended that I undergo a yearly or more frequent physical examination and consultation with my physician as to my participation in SEBA Programs. 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 SEBA Programs without the approval of my physician and do hereby assume all responsibility for my participation. I certify that I have read and understand all of the foregoing and by signing this release, I am legally bound to the provisions herein. Fitness Member Signature Family Member Signature (Required for family plan) Date Date Page 5 of 7

6 SEBA Fitness Center Security Regulations 1. SEBA Fitness Center facilities are for use by members only. 2. The SEBA Fitness Center membership is open to all who complete and sign an application and release of liability, and pay their user fee. Release forms and membership processing are available at the SEBA Store. 3. A SEBA Fitness Center member is an authorized fitness user, i.e. a paid user in good standing. 4. Spouses/Family members, who are members of the fitness center, must be accompanied by the NIST employee who is also a fitness center member when using the facility. 5. The facility is open 24 hours a day, seven days a week. The locker rooms and showers are closed 09:30 a.m. to 10:30 a.m. Monday thru Friday for cleaning. 6. To prevent unauthorized use of the SEBA Fitness Center, Security personnel, SEBA employees and officers are authorized to check identification. 7. All members are asked to help deter and prevent unauthorized access to the fitness facility. Escorting non-members into the facility is not permitted and may result in suspension of membership without refund. Guests entering any building after 6:30 P.M. (e.g. use of rest rooms) should be escorted by a NIST employee. 8. It is the responsibility of Fitness Center members to report any security/safety violation to the SEBA Store. Security/safety violations include but are not limited to: a. A. Unauthorized use of facilities. b. B. Abuse of facilities and/or equipment. c. C. Use of equipment in an unsafe manner. d. D. Unauthorized removal of equipment from facility. 9. SEBA Fitness Center users violating security/safety regulations face loss of facility privileges, as determined by the "SEBA Fitness Committee." Users losing membership privileges resulting from security/safety violations can only be reinstated by written approval from the "SEBA Fitness Committee." SEBA Fitness Center Rules The SEBA is responsible for the fitness facility and will assure the maintenance and repair of paint, tile, carpeting, lighting, heating/cooling, plumbing, electrical components, exercise equipment, and all other physical aspects of the facility to ensure that the facility meets all the requirements of the Occupational Health and Safety Division. The SEBA Fitness Center is an employee sponsored facility. It requires the cooperation of all users to maintain a clean, safe environment. I. Dress Code Clean, safe, appropriate exercise attire (including shoes) is required in the exercise room. Street clothes are not acceptable. A shirt must be worn at all times when in NIST buildings. Shoes and clothing worn in the Fitness Center must not damage the equipment. Page 6 of 7

7 Open-toed shoes, dress shoes, and work boots must be changed to gym-type shoes before using Fitness Center equipment. Hard soled shoes are prohibited on the aerobics floor. Soccer shoes, spikes, and footwear used for running or outside sports must be thoroughly cleaned or removed before entering the fitness center. Likewise, soiled footwear is not to be put on in the fitness center or locker rooms or worn when using the fitness facilities. II. Equipment Usage During peak times, users of the cardiovascular equipment (stairmaster, bikes, crosstrainer, and treadmill) will be limited to 20 min. intervals. Please do not use the free weights if you are the sole occupant. A spotter is recommended for all free weight lifting. All weights (including dumbbells) and equipment are to be returned to their designated location. (Not necessarily where you found them!). The Fitness Center does not employ anyone to do this. If you are unable or don't have the time to put the weights back on the racks please ask a colleague to help you. Please do not sit and rest on equipment while someone else is waiting to use it. III. Facilities Housekeeping and Maintenance 1. Use of chalk is not permitted. 2. Please return magazines and newspapers to the magazine rack. Unwanted newspapers and waste paper should be disposed of properly. 3. It is required that all perspiration be cleaned off of the equipment after use. In addition to bringing your own towel, SEBA will provide anti-fungal/anti-bacterial cleaning wipes for this purpose. Please properly dispose of any used cleaning materials. Do not remove rolls of paper from the locker/shower facilities for this purpose. 4. The changing room and shower facilities are for daily use by gym members. Overnight locks in the locker rooms are not permitted and will be removed. It is everyone's responsibility to help keep the locker room and showers clean and neat. A limited number of shoe lockers near the entrance door have also been provided. These may be reserved and locked through the SEBA Store. (NOTE: NIST & SEBA are not responsible for lost or stolen articles). IV. Conduct The volume level of music must be acceptable to the majority of present users. Please do not smoke, eat, or drink anything other than water in the exercise rooms. Page 7 of 7