Fitness Membership Application

    Your Information

    Format: (212) 555-5555 or international formats


    Assumption of Risk

    I am aware that the use of the Club’s facilities involves certain risks (some of the risks may include muscle soreness, muscle strain, shortness of breath, fainting and possibility a heart attack or other serious ailments that could result in death) of injury and I expressly assume the risk and responsibility for accidents or injuries of any kind which I or others may sustain by reason of my physical exercise and use of the Club’s facilities.

    Use of Facilities

    I agree to abide by all rules and regulations of the Club and I shall not use any exercise equipment that I am unfamiliar with without prior instruction by the Club’s Staff.

    Indemnity and Hold Harmless

    I assume the entire responsibility and liability for any and all damage or injury of any kind or nature whatsoever (including death resulting therefrom) to all persons including myself, employees of the Club or others and to all property including but not limited to property of the Club (including loss of use thereof), caused by, resulting from, arising out of, or occurring in connections with my use of the facilities of the Club and/or caused, or contributed to, by any negligent act, error, or omission on my part.

    I further agree to indemnify and hold the Club, its agents, officers, employees, members and volunteer workers harmless from any and all liability, loss expense (including attorney’s fees and disbursements), damage or injury that the Club or any such persons may sustain as a result of any accident, injury or other loss caused in any way by my use of the Club’s facilities or equipment, or in any way by my physical condition, illness or disease.



    Physical Activity Readiness Questionnaire (PARQ)

    We will use the Physical Activity Readiness Questionnaire (PAR-Q) to assist you in starting an exercise program. The Club’s collection and review of this information in no way constitutes a certification of your fitness to participate in any exercise program. In any case, HCNY Athletics recommends that you consult your physician before starting any exercise program and reserves the right to require written permission from your physician before you start this program.

    1. Has a doctor ever said that you have a heart condition and recommended only medically supervised activity?

    2. Do you have chest pain brought on by physical activity?

    3. Have you developed chest pain in the past month?

    4. Have you on one or more occasions lost consciousness or fallen over as a result of dizziness?

    5. Do you have bone or joint problems that could be aggravated by the proposed physical activity?

    6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, heart condition or cholesterol?

    7. Are you aware, through your own experience or doctor’s advice, of any other physical reason that would prohibit you from exercising without medical supervision?

    8. If female, and pregnant, has your doctor recommended restrictions to exercise?

    Source: Taken from Balady, Gary J, et al, ACSM/AHA Scientific Statement Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health and Fitness Facilities Medicine and Science in Sports and Exercise 1998; 2285

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