Intake Form - Spa Total Fitness Centre

Intake

"*" indicates required fields

What type of membership are you planning to purchase?*

One Year Single

One Year Couple

One Year Family

Your Name*

First Last

Email*

Name of Your Spouse or Common Law Partner*

This person will be referred to as your partner for the remainder of the form.

First Last

Name of Children, Their Ages and Gender*

Address*

Street Address Address Line 2 City Province Postal Code

Emergency Contact Name*

Emergency Contact Phone*

Your Digital Signature*

By entering your name here, you agree that this constitutes your digital signature.

Your Partner's Digital Signature*

By entering your name here, you agree that this constitutes your digital signature.

Refunds applied for after 15-day trial period will be charged a $60 administration fee. All programs, times, and services are subject to change.

Par-Q and You

Par - Q is designed to help you help yourself. Many health benefits are associated with regular exercise and the completion of Par - Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life.

For most people, physical activity should not pose any problems or hazard. Par - Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.

Common sense is your best guide in answering these few questions. Please read them carefully and check the yes or no opposite the question, if it applies to you.

1. This questionnaire applies to those 15 to 69 years of age.

2. If you have a temporary illness, such as a fever, or are not feeling well at the time, you may want to postpone the proposed activity.

3. If you are pregnant, you are advised to consult a physician before exercising.

4. If there are any changes in your status, relative to the above questions, please bring this information to the immediate attention of your fitness professional.

5. Membership runs for period of time as per application and may only be considered for cancellation if member is relocating out of province or for medical reasons in which a doctors certificate is required.

6. Memberships may be put on freeze for medical reasons; a doctor’s certificate is also required.

7. Programming times and hours of operation may vary from time to time.

Has your doctor ever said you have heart trouble?*

Yes

Has a doctor ever said your partner has heart trouble?*

Yes

Has a doctor ever said any of your children have heart trouble?*

Yes

Do you frequently have pains in your heart and chest?*

Yes

Does your partner frequently have pains in their heart and chest?*

Yes

Do any of your children frequently have pains in their heart and chest?*

Yes

Do you often feel faint or have spells of severe dizziness?*

Yes

Does your partner often feel faint or have spells of severe dizziness?*

Yes

Do any of your children often feel faint or have spells of severe dizziness?*

Yes

Has a doctor ever said your blood pressure was too high?*

Yes

Has a doctor ever said your partner's blood pressure was too high?*

Yes

Has a doctor ever had high blood pressure concerns regarding any of your children?*

Yes

Has your doctor ever told you that you have a bone or joint problem (such as arthritis) that has been aggravated by exercise or might be made worse with exercise?*

Yes

Has a doctor ever told your partner that they have a bone or joint problem (such as arthritis) that has been aggravated by exercise or might be made worse with exercise?*

Yes

Has a doctor ever told any of your children that they have a bone or joint problem (such as arthritis) that has been aggravated by exercise or might be made worse with exercise?*

Yes

Is there a good physical reason not mentioned here why you should not follow an activity program, even if you wanted to?*

Yes

Is there a good physical reason not mentioned here why your partner should not follow an activity program, even if they wanted to?*

Yes

Is there a good physical reason not mentioned here why any of your children should not follow an activity program, even if they wanted to?*

Yes

Are you over age 65 and not accustomed to vigorous exercise?*

Yes

Is your partner over age 65 and not accustomed to vigorous exercise?*

Yes

I have read, understood, and completed the questionnaire above.

Your Digital Signature*

By entering your name here, you agree that this constitutes your digital signature.

Your Partner's Digital Signature*

By entering your name here, you agree that this constitutes your digital signature.

Health and Release

When did you receive your last medical?*

When did your partner receive their last medical?*

Do you have any special medical problems?*

Does your partner have any special medical problems?*

Family Physician*

Does your partner have a different Family Physician?

Yes

Your Partner's Family Physician*

IN CONSIDERATION of permission being granted to me, the undersigned, by management of West Royalty Fitness Centre Ltd. to participate in the various activities offered and for the use of the various facilities, including all buildings, courts, pools, gymnasiums and equipment of any nature, I hereby release and discharge the West Royalty Fitness Centre Ltd. of West Royalty in Queens County, province of Prince Edward Island, its agents, employees and officers from all claims, demands, actions, judgements and executions which the undersigned ever had, or now has, or may have, or which the undersigned, his heirs, executors, administrators or assigns may have, or claim to have against the West Royalty Fitness Centre Ltd. of West Royalty, aforesaid, its successor or assigns for all personal injuries (however caused), known or unknown, and injuries to property real or personal caused by or arising out of, the above described activities or use of facilities.

Furthermore, it is agreed that the West Royalty Fitness Centre Ltd. of West Royalty, aforesaid, will be released of all liability arising from the damages, loss, removal or theft of any personal property belonging to, or in my care or custody, while on the premises of the West Royalty Fitness Centre Ltd. of West Royalty, aforesaid, for any whatsoever.

Furthermore, it is agreed upon reading and signing this application form, I agree to remit to the West Royalty Fitness Centre all monies incurred by myself, and all members of my family. It is understood that by signing this application form, I agree to pay for my membership in full.

I, the undersigned have read this RELEASE and understand all its terms. I execute it voluntarily and with full knowledge of its significance.

Your Digital Signature*

By entering your name here, you agree that this constitutes your digital signature.

Your Partner's Digital Signature*

By entering your name here, you agree that this constitutes your digital signature.

Once this form is submitted, you will be taken to a page to purchase your membership.
For any locker purchases please see the front desk on your first visit.

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