APPLICATION FOR MEMBERSHIP

Transcription

1 APPLICATION FOR MEMBERSHIP 2015 Staff - ID required Student - ID required Wellington Weight Lifting Club ID required. Petone Premier Team ID required and must be signed off as pre-approved team member by Dynamics Gym Manager. Date: Full Name: Address: Home Ph: Mob Ph: Date of Birth: / / (required) Male Female Occupation: Emergency Contact Details: In the case of any accident/incident your safety is paramount. Please provide the following details to assist us should any accident/incident occur. Emergency Contact Person: Relationship: Ph: Mob Ph: Name of Doctor: Doctor s Phone:

2 Pre-Screening Details: Before you undertake any exercise, we need to know whether it is safe for you to exercise. Please answer the following questions as it is imperative we evaluate your current capacity to participate in an exercise program. What benefits would you like to gain? (Please tick) Reduce Body Fat Sports Conditioning Rehabilitation Increase Endurance Body Building Improve Posture Improve Flexibility Strength Training Increase Muscle Mass/Tone Other How frequently would you be able to exercise per week? At present, what recreational activities or sports do you participate in? Please tick any of the following that apply to you. Ever had high blood pressure, high cholesterol or heart problems Do you suffer from breathing problems? Do you suffer from epilepsy, diabetes or kidney disease? Do you take prescribed medicine? Do you suffer from any joint pain? Do you suffer from back or neck pain? Do you have a family history of heart disease? Are you pregnant? Is there any medical reason why you shouldn t exercise? Do you ever have chest discomfort during exercise? Do you smoke? If yes, how long have you smoked & how many a day? Do you drink alcoholic beverages? If yes, how much in a week (indicate below) Beer: (cans) Wine: (glasses) Spirits/Liquor: (drinks) Do you drink caffeinated beverages? If yes, how much in a week? (Indicate below) Coffee: (cups) Tea: (cups) Soft drinks: (cans)

3 Do you have any current injuries? If you ticked yes to any injuries, please give a detailed description and any treatment received: Are you currently following a weight reduction diet plan? If yes, how long have you been dieting? (months) Is the plan prescribed by your doctor or a nutritionist Have you followed a weight reduction diet in the past? Activity Level Evaluation: What is your occupation activity level? (Please indicate below) Sedentary Light Moderate Heavy Do you currently engage in vigorous physical activity on a regular basis? If yes, what type? How many days per week? How long? (Please indicate below) <15mins min 30-60min 60 min

4 Membership Categories and Fees: Membership Type Fee Expiry Date Staff - TIASA Membership Staff Individual Contract Membership Petone Premier Team As agreed As agreed As agreed 11 Month Membership (mid Jan/Feb mid December) $400 8 Month Membership $315 6 Month Membership $250 3 Month Membership $150 1 Month Membership $75 PLEASE NOTE: All memberships expire at the end of each calendar year. No refunds. OFFICE USE ONLY: (please attach receipt) Amount Received: Date Received: Staff or Student Id # Drivers Licence or Birth Certificate required for all external memberships - please photocopy & attach to this application. Privacy Statement: The information you give on this pre activity questionnaire is collected for the primary purpose of advising you on the appropriateness of a doctor s clearance before exercising. Other purposes of collection include the creation of a record on Best Practice Personal Training database, attending to administrative matters and corresponding with you. No personal information collected from you will be passed on to any other organization without your consent.

5 Informed Consent: Thank you for choosing to use the facilities of Dynamics Gym, Weltec. We request your understanding and cooperation in maintaining both your and our safety and health by reading and signing the following informed consent agreement Please read and tick the box to show you understand and agree to the conditions: I,, declare that I intend to use some of or all of the facilities offered by Dynamics Gym, and I understand that each person (myself included), has a different capacity for participating in such activities, facilities, programs, and services. I am aware that all activities, services, and programs offered are educational, recreational, or self-directed in nature. I assume full responsibility, during and after my participation, for my choices to use or apply at my own risk, any portion of the information or instruction I receive. I understand that part of the risk involved in undertaking any activity or program is relative to my own state of fitness or health, (physical, mental, or emotional) and to the awareness, care, and skill with which I conduct myself in that activity or program. I acknowledge that my choice to participate in any activity, service, and programme brings with it my assumption of those risks or results stemming from this choice and the fitness, health, awareness, care, and skill that I possess and use. I further understand that the Dynamics Gym facilities are sometimes unsupervised and that any exercise not prescribed by an exercise professional may be dangerous to attempt without professional supervision. I understand that I am entitled to request an exercise programme and fitness assessment as part of my membership. I recognize that by participating in the activities, facilities, programmes, and services offered by Dynamics Gym, I may experience potential health risks including but not limited to transient light-headedness, fainting, abnormal blood pressure, chest discomfort, leg cramps, and nausea and that I assume wilfully those risks. I understand that I may stop or delay my participation in any activity or procedure if I so desire and that I may also be requested to stop and rest by a supervising employee who observes any symptoms of distress or abnormal response. I understand that I may ask questions or request further explanation or information about the activities, facilities, programs, and services offered by Dynamics Gym at any time before, during, or after my participation. I understand that any fitness relating testing undertaken is designed to help the instructor design a suitable fitness program that matches my current physical condition with my short and long term goals and help identify any potential health risks. I have read and understand the gym code of conduct On signing this agreement I understand and agree there will be no refunds if I decide not to attend the gym for the given membership term I will take appropriate precautions when using the Dynamics Gym facilities and will ensure that: I have a spotter (assistant) when using free weights. Safety collars are placed at both ends of the bar at all times. I ask for assistance when using free weights, machines and/or cardio equipment that I am unsure about handling on my own. Equipment is placed back to its original position. There is another member present when using the facility when it is not staffed. Sports shoes only to be worn during workout. Use a towel on all equipment. Wipe down equipment after use.

6 I have read the above information and understand it. Any questions concerning testing procedures have been answered to my satisfaction. I understand that any information gathered through these tests is confidential and will not be disclosed to anyone else without my permission. I understand that I am free to withdraw at any stage from procedures. I understand that at the time of signing this document the above details are correct. The information will be kept private and confidential and no information will be used anywhere else without my permission. Name Printed: Signature: Dated: Consultant: Dated:

7 Gym Code of Conduct The Gym Code of Conduct highlights the dos and don'ts for gym goers. These simple but often overlooked and commonly forgotten guidelines will allow for a far more pleasant experience the next time you attend Dynamics Gym. 1. SHARING OF EQUIPMENT As most gyms are often over crowded during peak hours, be considerate when using all equipment and machines. It is very easy to take turns in-between sets on any given piece of equipment. When doing cardio, do not go longer than 30 minutes on one machine. 2. WIPE DOWN EQUIPMENT There is nothing than getting on a piece of equipment that has not been wiped down. Respect the equipment and other gym goers by wiping your sweat off the bench, treadmill or whatever piece of machinery or equipment you have just used. Disinfectant spray and paper towels are provided in most cardio and equipment sections. 3. PERSONAL HYGIENE Just because you can't smell yourself, doesn't mean others can't. When you work out hard, you perspire and sometimes you will smell bad. Deodorize before and after and regularly wash your gym clothes after use. 4. RESPECT EACH OTHER'S SPACE This rule especially applies when in the free-weight section of a gym. Not only do people need their space to execute exercises effectively, they also need space in case something goes wrong. Keep your distance and do not become a distraction when someone is in the middle of their set. 5. CLEAN UP YOUR MESS Whether it's an empty water bottle, paper towel, chalk or a wrapper, do not leave your rubbish lying around the gym floor. Always double check your work area and leave it in the same condition you found it and replace/return all equipment in the appropriate storage area. 6. BRING A TOWEL When you are going to the gym, you should always bring a towel or two with you. Weltec does not provide towels. One towel is to put down on the machine you are using, and the other is for you.

8 7. PUT BACK WEIGHTS No one likes getting to a piece of equipment they've been waiting for only to discover they have to remove 360lbs of plates from it. Also, no one likes having to search the entire gym for a certain weight. Please put your dumbbells, barbells and any attachments back when you are finished with them. 8. DRESS CODE People go to the gym to work-out, not to stare and gawk at you or anybody else. T-shirt, shorts, sweat pants and runners are perfect choices. Sports bras, under shirts, short shorts and sandals are not. Also, remember your indoor runners and leave your street shoes in the locker room. Failure to be dressed appropriately will restrict entry as this is a health and safety risk. 9. NOT A SOCIAL GATHERING It's a gym and not a bar or restaurant. You are here to exercise, not to socialize with friends. Stay off your cell phone, don't tie up equipment you aren't using and try and stay focused. 10. VOLUME CONTROL Nothing is more distracting and annoying than ringing cell phones, listening to other people's ipods through blaring headphones, the sound of slamming dumbbells on the floor, and excessive and unnecessary grunting and growling. Remember, it's a public gym and not your basement. So respect the gym, respect others using the gym, and most importantly, respect yourself and your fitness goals which are the reason you are there in the first place. Take care of your gym and your gym will take care of you 11. ACCESS Your gym card is for your access only. You must not invite friends or family to use the gym or give any non-member access to the gym. Failure to comply will result in your membership being revoked. 12. CHILDREN Please refrain from bringing your children to the gym while you train. Alternative childcare must be arranged.