Welcome to the LeVerne Carlson Fitness Center!

Transcription

1 Welcome to the LeVerne Carlson Fitness Center! Thank you for your interest in the LeVerne Carlson Fitness Center. This packet of information includes: membership rates, payment options, rules of the fitness center and membership enrollment forms. If you are interested in becoming a member of our facility, please read and complete this packet. An enrollment checklist is available to follow on page 2. Signatures are required on several documents that acknowledge you understand and agree to adhere to the terms stated. Copies of all these documents are available upon your request. Our fitness center has agreements with many medical insurance companies to offer fitness rewards reimbursements. Ask whether your company is one of them. We also participate in the Silver & Fit program which is offered through many Medicare insurance plans. We submit your workouts to your medical insurance on your behalf. Please Note: Due to HIPAA laws, we are unable to access your medical insurance policy benefits. You will need to check with your insurance provider to see if your policy carries this benefit. In order to track workouts individually and accurately, each member seeking this reimbursement is required to have their own key card. Again, thank you for your interest in the LeVerne Carlson Fitness Center. We believe our fitness center has a lot to offer, and we look forward to you being able to enjoy this great facility. If you have any questions, comments or concerns regarding our fitness center, please contact: Jenny Hovendick Fitness Center Coordinator , option 1 jhovendick@ac242.us Alden-Conger Public School 215 North Broadway P.O. Box 99 Alden, MN 56009

2 What do I need to register as a member? 1. Completed Member Information Form 2. Signed Membership Agreement 3. Signed Guidelines Form 4. Signed Payment Options Form 5. Membership fee of $ % sales tax received or automatic withdrawal set up (No fees for Silver & Fit) 6. $ % sales tax for each key card (No fees for Silver & Fit) 7. If applicable: A voided check for the automatic withdrawal payment option 8. If applicable: Signed Health Insurance Enrollment Form (Enrollment forms are available in the fitness center office.) 9. If applicable: A copy of medical insurance card 10. If applicable: Signed Bank Authorization Form for receiving fitness reimbursement deposit to member s checking or savings account (Bank Authorization Forms are available in the fitness center office.) Copies of all documents submitted are available upon request.

3 LEverne Carlson FITNESS CENTER Member Information Students must be in Grades 9-12 in order to be a member of the LeVerne Carlson Fitness Center. Students in Grades 7-8 may be allowed on Family Memberships, but must be supervised by a parent/ legal guardian at all times. Family members include students who are in Grades 7-8, or full-time students under the age of 23. Membership Type Primary Member s Name Family Member s Name Family Member s Name Family Member s Name Family Member s Name Start Date _ Address City State Zip Home Phone Cell Phone Emergency Contact Person Medical Insurance Company Emergency Contact Phone Number ALL MEMBERS LISTED MUST PROVIDE A COPY OF THEIR MEDICAL INSURANCE CARD TO BE ELIGIBLE FOR FITNESS DISCOUNTS FROM ANY INSURANCE COMPANY.

4 LeVERNE CARLSoN FITNESS CENTER Membership Agreement WAIVER AND RELEASE OF LIABILITY In consideration of the Alden-Conger Public School permitting members and their guests and invitees to utilize the LeVerne Carlson Fitness Center facilities, and with the understanding that the undersigned is under no obligation to join or use this facility but does so of his/ her own free will, the member agrees to abide by all the membership rules of the facility and acknowledges as follows: WARNING The undersigned fully understands and acknowledges that there are certain risks and dangers inherent in exercise and strenuous physical activity. Because use of these facilities can involve strenuous physical activity, there is an inherent risk of serious injury, illness or even death. Therefore, each member, guest or invitee who uses this facility is urged to obtain a physical examination from a doctor prior to using the exercise equipment or engaging in the physical exercise activities offered by the facility. ASSUMPTION OF RISK In addition, each member, guest or invitee agrees to assume all risk of injury, illness, death, damage or loss by theft in regard to any use of this facility including, but not limited to, the locker room, parking area, sidewalk area, or any equipment in the fitness center or weight room including participation in any activity, class or program offered at the facility. STATEMENT OF WAIVER AND RELEASE Each member, guest or invitee on his/her behalf and on behalf of their dependents, heirs and assigns hereby voluntarily agrees to release, waive, discharge, hold harmless, defend and indemnify the Alden-Conger School District and its officers, agents, past and present school board members, and employees, for any and all claims, actions, or losses for bodily injury, property damage, wrongful death or otherwise which may arise out of my use of the premises. The undersigned specifically understands that he/she is releasing, discharging, and waiving any claims or actions that he/ she may have presently or may have in the future for negligent acts, by the school district, or its officers, agents or employees. To the fullest extent permitted by law, the undersigned understands that if an action is brought against the school district or any of its employees, school board members, agents or insurers which in any way arises out of the undersigned use of occupancy of the premises, the undersigned agrees to defend all actions at his/ her expense and will agree to pay all attorneys fees, courts costs and other expenses of any kind and character and satisfy a judgment rendered against the school district that may arise from their use. This waiver and release of liability includes, without limitation, all injuries, illness or death which occur regardless of negligence as a result of: a) use of the exercise equipment, b) the sudden and unforeseen malfunctioning of any equipment, c) instruction of supervision provided by the school district, and d) the undersigned slipping and/ or falling while in the fitness center, or on the school district s premises, including adjacent sidewalks and parking areas. THE UNDERSIGNED HAS READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREES THAT IT IS HIS/HER INTENTION TO EXEMPT AND RELEASE THE SCHOOL DISTRICT FROM ANY AND ALL LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR FAULT. HOWEVER, THIS WAIVER DOES NOT APPLY TO LIABILITY FOR INTENTIONAL, WILLFUL, OR WANTON ACTS ON THE PART OF THE SCHOOL DISTRICT, ITS AGENTS OR EMPLOYEES. This contract will remain in effect at all times of active membership. Signature (Member, Guest, Invitee) Date

5 LeVERNE CARLSoN FITNESS CENTER Guidelines CHECKING IN * All members are required to scan their cards at the door. Guests must sign in on the clipboards. There is a limit of 2 visits per guest. MEDICAL CONDITIONS * If you have any medical condition inhibiting exercise, you are responsible to take all necessary precautions and assume any and all risks. No exercise program should be undertaken without the advice of your physician. * If you should incur an injury while at the fitness center you acknowledge that it is your responsibility to seek appropriate care. UNATTENDED CHILDREN * All children under grade 9 must be accompanied by an adult or guardian over the age of 18. VALUABLES AND PERSONAL PROPERTY * The Alden-Conger School District will not be held liable for the loss by theft or damage to personal property. MEMBERSHIP CARD * Initially there will be a $15.00 charge for a membership entry key card. * Your access card will be used to record your visits to the fitness center for submittal to the various insurance companies participating in the fitness discount program. * If you lose your membership card there will be a $15.00 charge to cancel the lost card and issue you a new one. It is imperative that you notify us immediately if your card is lost or stolen. You may be held accountable for any damage that occurs through the use of your lost or stolen card. * A person that allows others to use their card will have their membership immediately cancelled with no refund of membership fees. * If you decide to stop your membership, but later decide to return, there is a $10.00 fee to re-activate your card. AGE * Children 6 th grade or younger are not allowed in the lower level strength room. * Children 6 th grade or younger are not allowed to use the cardio equipment on the second floor. * A child in the 7 th and 8 th grade may use the equipment under the direct supervision of an adult. * Students from 9 th to 12 th grades may be issued a card either by single membership or as part of a family membership. PROPER ATTIRE * Shirt and shoes are to be worn at all times while working out. Clothing with belts, buckles, snaps, etc., should not be worn as they can damage equipment. The wearing of clothing containing offensive words, graphics, or references to alcohol or tobacco products is not allowed. EQUIPMENT CLEANUP * Please show consideration for the next person by wiping off the machine with the disinfectant towels provided. EXERCISE AND STRENGTH ROOM * You are responsible to use the equipment as intended. Misuse may result in damage, which you will be responsible for the cost to repair. * Profane language is not allowed. * Malfunctioning equipment should be reported to the high school office. Do not attempt to fix it yourself. * Plate loaded free weights can only be used when a spotter (someone who is able to assist you with the weight) is present. No one is allowed to lift free weights when alone. Failure to comply may result in loss of membership. RIGHT TO CANCEL * A member may terminate their contract at any time by giving a written request to the school business office. Requests must be in by the 15 th of the month to avoid being charged for the next month. There will be no pro-rated refunds. Unless the member terminates, the membership will automatically be renewed on a month-to-month basis. Penalty for breaking these and other posted rules will be loss of membership. Refunds will not be issued. Signature Date

6 LeVerne Carlson Fitness Center Payment Options Member Name Member Number PREPAID YEARLY MEMBERSHIP AMOUNT $ TYPE: Automatic Withdrawal (from a checking or savings account) * Personal Check or Cash MONTH-TO-MONTH MEMBERSHIP AMOUNT $ TYPE: Automatic Withdrawal (from a checking or savings account) * Personal Check or Cash I UNDERSTAND MY CHOICE OF PAYMENT. IF I HAVE CHOSEN THE PERSONAL CHECK OR PAYSCHOOLS OPTION FOR MY YEARLY MEMBERSHIP, I UNDERSTAND IT IS MY RESPONSIBILITY TO MAKE THE NEXT YEAR S PAYMENT ON OR BEFORE THE 1 ST OF THE MONTH OF THE ANNIVERSARY OF MY MEMBERSHIP. ALL AUTOMATIC WITHDRAWS WILL ALSO BE PLACED ON THE 5 TH OF EVERY MONTH. I ALSO UNDERSTAND MY PRE- PAID METHOD OF CHOICE WILL BECOME MY MONTH-TO-MONTH PAYMENT METHOD FOR EVERY MONTH THEREAFTER. Signature Date Printed Name * Fill out section below only if you are choosing automatic withdrawal for payment of your membership. FOR AUTOMATIC WITHDRAWAL OPTION: Please pay and charge all drafts by LeVerne Carlson Fitness Center to its own order on the 5th of each month in the amount of beginning. This authorization will remain in effect until canceled by me in writing, and you actually receive such notice, I agree that you shall be fully protected in honoring such drafts. I agree that your treatment of each draft, and your rights in respect to it, shall be the same as if it were signed personally by me. All returned non-working accounts automatically default to an additional billing of $20 per month. Bank Name Checking Savings Account Number Routing Number Signature Date Printed Name PLEASE ATTACH A VOIDED CHECK OR SAVINGS ACCOUNT DEPOSIT SLIP.

7 LEVERNE CARLSON FITNESS CENTER Membership Rates Reside in the City of Alden Rates Reside Outside the City of Alden Rates Monthly Yearly Monthly Yearly Single $20.00 $ ($15.00/mo) $25.00 $ ($18.75/mo) Family $30.00 $ ($22.50/mo) $35.00 $ ($26.25/mo) Senior (Age 60 and over) Senior Couple (Both must be seniors) Walking Track Only Senior $15.00 $ ($11.25/mo) $25.00 $ ($18.75/mo) $5.00 $45.00 ($3.75/mo) $20.00 $ ($15.00/mo) $30.00 $ ($22.50/mo) $7.00 $63.00 ($5.25/mo) Walking Track Only Non-Senior $7.00 $63.00 ($5.25/mo) $10.00 $90.00 ($7.50/mo) Monthly Yearly All Alden- Conger Students (Grades 9-12) $5.00 $45.00 ($3.75/mo)

8 ***Information and forms regarding the Health Insurance Fitness Rewards Programs are available upon request at the fitness center office.***