Title: Mr / Mrs / Ms / Miss. First Name: Surname: GENDER: M/F D.O.B.: / / AGE: years

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1 MEMBERSHIP FORM New Member- Renewing Member 1. MEMBER DETAILS Title: Mr / Mrs / Ms / Miss Date: / / First Name: Surname: GENDER: M/F D.O.B.: / / AGE: years Address: Suburb: Post Code: Phone: (H) (Mob) (Wk) EMERGENCY CONTACT 1: PHONE: EMERGENCY CONTACT 2: PHONE: 2. MEMBERSHIP TYPE (A) Fast Card Adult (Monthly direct debit) Student/Concession Note: (Monthly direct debit) $ months $ 42 per month $ months $ 24 per month Fastcard Memberships are for the use of the Weight Gym Only. Fastcard monthly memberships are an ongoing membership debited directly from a nominated bank account or credit card account. There is no minimum term and debits will continue until cancellation is made in writing. continue until cancellation is made in writing. (B) Annual membership (entry fee per visit additional) Adult $50.00 Student/Child $30.00 Concession $30.00 Family $60.00 Police Free Spec Free (C) 1 Month Membership (no visit fees) Adult $65.00 Student/Concession 3. STAFF ONLY Total Fees received: $ Cash/Cheque/EFT/Direct Debit Receipt No: Membership No: ACTIVITY: Join Date: / / Expiry Date: / / Card Done: Yes/No Staff: ID Sighted:

2 PRE-EXERCISE SCREENING QUESTIONNAIRE This screening tool does not provide advice nor does it substitute for advice from an appropriately qualified medical professional. No warranty or safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Hobart PCYC for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool. Anyone who has an existing medical condition or who has not exercised for 6 months or more is advised to seek medical clearance before starting an exercise program. It is your responsibility to make sure you are cleared to exercise and participation is at the discretion of the individual. Hobart PCYC reserves the right to refuse entry in some instances. NAME: Date: / / STAGE 1 1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke? 2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? 3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you Name: to lose Date: balance? 4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12mths? 5. If you have diabetes (typei or typeii) have you had trouble controlling your blood glucose in the last 3mths? 6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise? 7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? IF YOU ANSWERED to any question, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise. IF YOU ANSWERED to all the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise. 1. Age Gender STAGE 2 AIM: To identify those individuals with risk factors or other conditions to assist with appropriate exercise prescription. This Stage to be administered by a qualified exercise professional. RISK FACTORS 2. Family History of heart disease (eg: stroke, heart attack - immediate family) Relative: Age: 3. Do you smoke cigarettes on a daily or weekly basis or have quit smoking in the last 6 months? 4. Have you been told that you have high blood pressure? 5. Have you been told you have high cholesterol? 6. Have you been told you have high blood sugar? Age: 7. Describe your current physical activity/exercise (circle) Sedentry Light Moderate Vigorous No of Sessions p/w 8. Have you spent time in hospital (including day admission) for any medical condition/illness/injury during the last 12 months 9. Are you currently taking prescribed medication(s) for any medical condition? 10. Are you pregnant or given birth within the last 12 months? 11. Do you have any muscle, bone or joint pain or soreness that is made worse by particular types of activity? I believe to the best of my knowledge, all of the information I have supplied within this tool is correct. I understand I must advise the club immediately if my current physical or medical status changes in the future. Signature: Parent/Guardian Date: Staff auth: >45yrs Male or >55yrs Female = +1 Risk Factor Male<55yrs = +1 Risk Factor Female<65yrs= +1 Risk Factor (Maximum of 1 risk factor) = +1 Risk Factor = +1 Risk Factor = +1 Risk Factor = +1 Risk Factor <150 min/week = +1 Risk Factor >150 min/week = -1 Risk Factor If yes, provide details: If yes, what is the medical condition: If yes. provide details. I am months pregnant or postnatal (circle) If yes, provide details: > 2 RISK FACTORS - MODERATE RISK CLIENTS Individuals at moderate risk may participate in aerobic physical activity/ exercise at a light or moderate intensity (refer to the exercise intensity table) < 2 RISK FACTORS - LOW RISK CLIENTS Individuals at low risk may participate in aerobic physical activity/exercise up to a vigorous or high intensity (refer to the exercise intensity table) RISK TO-

Full Name Address DIRECT DEBIT REQUEST Customer details: Suburb Phone DOB Postcode Email Gender: Male/Female (please circle) Payment details: A single payment of $ A recurring fortnightly payment of

3 Full Name Address DIRECT DEBIT REQUEST Customer details: Suburb Phone DOB Postcode Gender: Male/Female (please circle) Payment details: A single payment of $ A recurring fortnightly payment of $ commencing from This is an ongoing direct debit membership agreement. Membership deductions will continue to be debited until you cancel this membership. Notification must be done in writing. I have read and understood this statement Debit options: Direct Debit Payment I authorize and request Hobart PCYC to debit, until further notice in writing, the nominated bank/financial institution account, below, as per the payment details above. OR Credit Card Payment I authorize and request Hobart PCYC to debit, until further notice in writing, the nominated Credit Card account, below, Account name Bank/institution Bank branch BSB (branch no.) Account number Name on card Credit card number Expiry date Type: Visa Mastercard Authorised signature: Authorised Signature: Date: Date: / /20 / /20 By signing this Direct Debit Request I acknowledge that I have read and understood the terms and conditions governing the debit arrangements between myself and Hobart PCYC as set out in this Direct Debit Request. Debits are processed on the first working day of each month and I agree that if the payment fails or rejects I will be liable for a $30.00 dishonor and processing fee for each failed direct debit. Monthly debits will continue until cancelled in writing. Cancellation will take affect at the end of the month of cancellation. There is no refund of pre-paid membership fees when cancelling. Memberships and payments may be suspended for periods of inactivity up to 8 weeks per 12 months with a minimum suspension period of 2 weeks. Hobart PCYC reserves the right the change the membership debit fee after notifying you via the above address or phone number. It is your responsibility to keep these details up to date.

4 HOBART POLICE AND COMMUNITY YOUTH CLUB INC TERMS AND CONDITIONS The following important information affects your legal rights and obligations. Please read this document carefully and sign to indicate you have understood and agree to the conditions of undertaking activities at the Hobart PCYC. Do not sign this document or undertake activities unless you are satisfied that you understand this document and agree. If you are less than 18 years of age a parent or guardian must read and understand this form and also sign. By signing this form you acknowledge and agree to the following:- General I acknowledge and agree that the activities organised and conducted by the Hobart PCYC (PCYC), including but not limited to weight gym and fitness, senior fitness classes, gym sports, self-defence classes, disability activities and other associated activities expose me to inherent dangers and risks, including the risk of injury or death. I acknowledge and agree that whilst the PCYC may have made every effort to reduce the above mentioned risks, these are risks inherent in my participation in all activities associated with PCYC and that due to the nature of PCYC activities it would be unreasonable for PCYC to be in any way responsible for any injury or death that I may suffer. I acknowledge and agree that I am undertaking the PCYC activities freely, voluntarily and absolutely at my own risk and with full appreciation of the nature and extent of all risks involved in PCYC activities. Safety Requirements I acknowledge and agree that whilst PCYC may have made every effort to reduce the risks and hazards associated with PCYC activities, there are numerous hazards that can occur whilst participating in PCYC activities, whether at the PCYC premises or not. I acknowledge that due to the nature and layout of PCYC s multipurpose facility, environmental factors such as equipment layout may create hazards, including but not limited to trip and slip hazards. I acknowledge and agree that I have an obligation to participate in PCYC activities in accordance with all safety requirements and with regard to other participants. I agree to adhere to the rule and general codes of conduct set out by PCYC or as otherwise directed by PCYC. I acknowledge that if I fail to observe these rules and directions I may be asked to leave the premises or have my membership suspended or cancelled in accordance with the PCYC Constitution. Medical Conditions I agree to inform PCYC of any medical conditions or existing injury that may impair my ability to participate or increase my chance of further injury or harm by truthfully completing the PCYC Medical Clearance Form to the best of my knowledge. I hereby give my consent to first aid care, hospital care and/or medical assistance which PCYC, and its agents consider appropriate or necessary in at that time I am not able to give my consent due to unconsciousness or other medical incapacity. I agree to meet any expense associated with such medical assistance. I acknowledge and agree that PCYC has no responsibility for my treatment or transport should I sustain an injury whilst participating in PCYC activities.

5 Promotion I acknowledge and agree that I may be photographed or filmed whilst undertaking activities with PCYC and these may be used for promotional purposes by PCYC. I hereby give permission to use my name, image, likeness and my performance in any PCYC activity at any time for any purpose whatsoever without any form of reimbursement. I will inform PCYC if I do not agree to this term. Indemnity with respect to PCYC activities To the extent permitted by law, I release PCYC, its related entities and agents (including their respective directors, officers, employees, contractors, teams, agents, mentors and volunteers) ( the Indemnified Group ) from any liability for any damages, loss, liability or injury I may suffer or incur (whether fatal or otherwise) relating to or arising out of my participation in PCYC activities and use of any piece of equipment designed for or used for the purpose of providing PCYC activities, whether the PCYC activities are on-site at any property owned or occupied by the PCYC or off-site ( the Facilities ), howsoever caused. I agree and acknowledge that I am waiving my right to proceed with respect to any contractual rights, express or implied, that may arise in relation to my relationship with PCYC (or casual use at any other time) and any claims that I may have in relation to breach of duty or negligence. I agree to indemnify on a continuing basis and on a full indemnity basis the Indemnified Group and each of them for any damage, loss of liability or injury that one or more of the Indemnified Group may suffer or incur (including by indemnity to third parties) as a result of my wilful, reckless or negligent conduct at or in the course of any PCYC activities, including without limitation the use of the Facilities. Payment I agree to pay the costs of attending PCYC including class or training session fees, PCYC membership fees, specific activity Insurance and Registrations fees (eg Gymnastics Australia or Boxing Tasmania Fees), Administration or Equipment Levies and other associated fees outlined on the Club Invoices or the Website/ Brochures. I also agree to pay the costs of any additional Competition Entry Fees, Grading Level Badges, Event Fees or other costs that I may opt to incur. I agree that if my payment is not paid or a regular payment plan (maximum 52 weeks) organised and adhered to under the set terms and conditions, that I will pay an additional Administration Fee of $25.00 where the invoice is over 30 days to cover the cost of chasing the dept, that I will be liable for a $30.00 dishonor and processing fee for each failed direct debit AND I will pay all Collection Agency Fees if the Dept is sent to a Collection Service after 90 days. I agree that if I am having difficulty paying an invoice or other PCYC cost that I will make an appointment to speak to the General Manager (or nominee) that has discretion in these matters, about organising a Payment Arrangement or other Arrangement. Legal Advice I confirm that I have been advised to obtain legal advice before signing this acknowledgement. Member Signature: Date: Parent/Guardian Signature: Date:

Name...Member Number... Team Name... OPERATING SINCE at Trinity College. STARplex. Membership Application Form

Name...Member Number... Team Name... OPERATING SINCE 2000 at Trinity College STARplex Membership Application Form STARplex...it s all right here! Membership Application If your membership is for a Fixed