12612 Hwy #50 – Suite 11A, Bolton, On L7E 1T6,
www.revivefitness.ca
905-951-1219
admin@revivefitness.ca
MEMBERSHIP & TERM CONTRACT/REGISTRATION FORM
Purchasers Name (First/Last)
Birth Date
Today’s Date
Day/Month/Year
Apt.#/Suite #
Street Address
Home Phone #
City
Cell Phone#
Postal Code
Business Phone#
List Medical Condition
Email Address
Emergency Contact Name
Emergency Contact Phone #
If user is someone other than the PURCHASER, please fill in below. (PURCHASER is wholly responsible for all the payment conditions of this agreement)
Bought for: First Name/Last Name (if different from above)
List Medical Conditions for Member
DOB
DD/MM/YR
Special instructions required:
Administration Section
MEMBERSHIP & TERM CONTRACT DETAILS
Year
Renew
Y/N
Initial
Months
(circle one)
3
6
12
3
6
12
3
6
12
3
6
12
3
6
12
Begin
DD/MM/YR
Expire
DD/MM/YR
Annual
Rate
Registration
Fee
Promo
Pro-Rate
Total
HST
Total
Down Payment
FINANCE DETAILS – Post Dated Cheques - FIXED MONTHLY PAYMENT AMOUNT: _______________________________
Year
Q#
Mnth
Q#
Mnth
Q#
Mnth
Q#
Mnth
Q#
Mnth
Q#
Mnth
Q#
Mnth
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Mnth
Initial
REGISTRATION DETAILS:
THE MEMBER ACKNOWLEDGES HAVING READ THE TERMS AND CONDITIONS ABOVE, THAT THESE TERMS AND CONDITIONS HAVE BEEN EXPLAINED TO MEMBER AND AGREES THAT THE TERMS AND
CONDITIONS SET OUT HEREIN AND ON THIS CONTRACT FORM PART OF THE AGREEMENT. The undersigned hereby authorizes Revive Fitness to draw monthly cheques by paper, covering payments by the
undersigned to Revive Fitness for the approved financing schedules.
1) All amounts “payable” to Revive Fitness drawn on or directed by you by a chartered bank on behalf of Revive Fitness
2) Your treatment of each debt shall be the same as if the undersigned has personally directed you to pay indicated and to charge the amount specified to the amount of the undersigned.
3) Any delivery of this authorization to you constitutes delivery by the undersigned.
4) Your signature on post dated cheques will qualify as signature to the contract
Member’s Signature
Employee’s Signature
******PLEASE TURN OVER TO SIGN THE CONSENT ON THE REVERSE SIDE
REVIVE FITNESS
Revive Admin Master Documents/NEW BUSINESS DOCUMENTS/Clients Forms/Section 6 – Client Forms/Membership contract
Today’s Date (DD/MM/YR)
12612 Hwy #50 – Suite 11A, Bolton, On L7E 1T6,
www.revivefitness.ca
admin@revivefitness.ca
MEMBERSHIP & TERM CONTRACT/REGISTRATION FORM
This Authorization is valid for the total period of participation – renewals included
Authorization, Informed Consent and Waiver Agreement
Participation in Physical Fitness Training
Revive Fitness
25 Mill Street, Bolton, ON L7E 1C1
905-951-1219
info@revivefitness.ca
www.revivefitness.ca
Please review the information below. If any area of this form seems unclear
or you disagree with any form or part, please ask for clarification.
Print Name and Sign Clearly. Thank you
PLEASE REVIEW THE INFORMATION BELOW. IF ANY AREA OF THIS FORM SEEMS UNCLEAR OR YOU DISAGREE WITH ANY FORM OR PART, PLEASE ASK FOR
CLARIFICATION.
PRINT NAME AND SIGN CLEARLY. THANK YOU.
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Authorization signing by Primary Registrant for all participants listed on this registration form.
Personal information contained on this form is collected in confidentiality and will be used to sign in your attendance and to record
any medical information (if required).
Questions about this collection should be directed to REVIVE FITNESS.
Permission is hereby granted to REVIVE FITNESS or its representatives to transport you or your child/ren or spouse/partner to a
local doctor or medical treatment centre if necessary.
I agree to release, discharge, to indemnify and save harmless REVIVE FITNESS from and against all claims or proceedings in
respect of any costs, losses or damages or injuries.
I agree to any medical attention and accept inherent risks associated with this program.
This Release, Waiver and Hold Harmless Agreement is made by and between the undersigned participant and REVIVE FITNESS
and entered into on the day, month and year noted below for all participants within this form.
REVIVE FITNESS provides instruction in Fitness Training, using the movement of the body in physical activity developed by those
instructing.
The parties to this agreement recognize that the activities could lead to physical injury to the participant.
The participant desires to take on the program(s) offered by REVIVE FITNESS with the full knowledge of the possibility that
physical injuries could result from it and desires to assume risk of any such injury.
The parties recognize that REVIVE FITNESS will not be able to provide its programs to the participants without execution of this
agreement.
All participants and parents agree that any picture taken at the program may be used in any promotion, without any further
consideration to the participant or family.
It is agreed that the participants within this waiver do not have any physical and hearth conditions that limit physical fitness
activities of any kind.
I/We hereby release and indemnify Revive Fitness and its officers, directors, employees and agents of any and all claims, damages of any
nature whatsoever arising as a result of any accident, injury or loss however sustained, by the participant and have read and understand the
terms of enrolment and give full authority to REVIVE FITNESS to act on my behalf in the event of an emergency. Therefore, participant(s), in
consideration of the above and of the exercise instruction to be provided, hereby waives all claims for damage or loss to person or property
which may be caused by any act, of REVIVE FITNESS instructors, staff, volunteers, landlord and their officers, agents or employees.
Participant assumes the risk of all the dangerous conditions in or around the premises and waives any and all specific notice of the existence
of such conditions. Participants also assume the risk of any and all injuries that might result from participating in the REVIVE FITNESS
exercise programs.
I, __________________________________ (Participants Name or Parent/Guardian of Participant) hereby affirm
that I have read the fully understood the above, and am over eighteen (18) years of age signing this waiver,
informed consent & release authorization to participate for all registrants on this registration.
Today’s Date
Participant over the age of 18/Parent/Guardian Signature
OUR GUARANTEE
Thank You for registering with
REVIVE FITNESS.
It is our hope that you thoroughly enjoy your program.
If at any time your expectations are not met please let us know as we will do everything we can to satisfy your concerns.
We can be reached at 905-951-1219
REVIVE FITNESS
Revive Admin Master Documents/NEW BUSINESS DOCUMENTS/Clients Forms/Section 6 – Client Forms/Membership contract
905-951-1219
12612 Hwy #50 – Suite 11A, Bolton, On L7E 1T6,
www.revivefitness.ca
admin@revivefitness.ca
MEMBERSHIP & TERM CONTRACT/REGISTRATION FORM
PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT
1)
CONSENT & RELEASE-I wish to participate in the exercise and training program offered by Revive Fitness.
I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I
have been examined by a physician of my choice and have obtained his/her approval for my participation in
a fitness program within) 60) days of the date set forth below. No change has occurred in my physical
condition since the date such approval was given which might affect my ability to participate in the fitness
program. If a physician has not examined me, I agree to see a physician within (60) days of the date set
forth below to obtain his/her approval for my participation in a fitness program. I agree that Revive Fitness
shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program
(whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness
facility) and I expressly release and discharge Revive Fitness its owners, employees, agents and/or assigns
from all claims, actions, judgements and the like which I or my heirs, executors, administrators or assigns
may have or claim to have as a result of any injury or other damage which may occur in connection with my
participation in the fitness program, expecting only an injury caused by the gross negligence or intentional
act of such person or persons. This Release shall be binding upon my heirs, executors, administrators and
assigns.
2)
PAR Q & RISKS-I certify that the answers to the questions outlined on the PAR-Q form are true and
complete to the best of my knowledge. I acknowledge that medical clearance is required if I have answered
“Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform
all employees of any conditions or changes in my health, now and on-going, which might affect my ability to
exercise safely and with minimal risk of injury.
3)
RIGHT TO REFUSE-I understand that I am not obligated to perform nor participate in any activity that I do
not wish to do, and that it is my right to refuse such participation during my training sessions. I understand
that should I feel lightheaded, faint, dizzy, nauseated or experience pain or discomfort, I am to stop the
activity and inform my Trainer, Group Fitness Instructor or alternate staff.
4)
GUARANTEE OF RESULTS-I understand the results of any fitness program cannot be guaranteed and my
progress depends on my effort and cooperation in and outside the sessions.
5)
TOUCH TRAINING-I understand that during a personal training or group training session, my
trainer/instructor may have to use Touch Training to correct alignment and/or to focus my concentration on a
particular muscle area to be targeted. If I feel uncomfortable or experience any type of discomfort with Touch
Training, I will immediately request that it be discontinued.
6)
CHANGE OF TRAINER/48 CANCELATION POLICY-I understand that should my Personal Trainer become
ill or is away on holidays, another trainer will be assigned to me so that my fitness progress does not suffer. I
also understand that in the event that my Personal Trainer is no longer employed by Revive Fitness. A
suitable Personal Trainer will be assigned to oversee my progress and workout sessions. I understand that
Revive Fitness operates on a scheduled appointment basis for all Private Training sessions and thus,
requires that I provide 48 hours notice when cancelling an appointment. No charge will be levied should I
cancel with more than 48 hours notice. Should I cancel a session under this period of time, I will be charged
for that session and work will be completed on my program in my absence. I understand that Revive Fitness
recommends that all cancelled sessions be rescheduled to ensure consistency and fitness progress.
7)
TRAINING NON-TRANSFERABLE/REFUNDABLE & PASSES EXPIRE AFTER 3 MTHS-I understand that
Revive Fitness bills its clients on a pre-paid basis. Once I have decided on the type of training package and
payment plan I will purchase, payment must be made before the sessions or terms are conducted. Cash and
cheques made Payable to: Revive Fitness is accepted. I understand that all training is non-transferable and
non-refundable. I also understand that all Private Training sessions must be redeemed within 1 year of
purchase, and Passes must be redeemed within 3 months of purchase.
8)
NUTRITIONAL SUPPLEMENTS-I understand that the usage of any nutritional supplements is done under
my own will and has not been prescribed by my Personal Trainer or any other staff member.
REVIVE FITNESS
Revive Admin Master Documents/NEW BUSINESS DOCUMENTS/Clients Forms/Section 6 – Client Forms/Membership contract
905-951-1219
12612 Hwy #50 – Suite 11A, Bolton, On L7E 1T6,
www.revivefitness.ca
admin@revivefitness.ca
MEMBERSHIP & TERM CONTRACT/REGISTRATION FORM
9)
PICTURE/MEDIA-I understand that Revive Fitness photographs many of their client events/sessions and I
provide written approval for them to use these pictures for promotional purposes.
10) HOLD/FREEZE-I understand that Class Passes, Personal & Team Training Contracts and Specialty
Programs purchases cannot be put on hold or transferred. Payment is to be received in full with the
exception of 1 year term contracts in which payment may be made at the start of the term with post-dated
monthly payments for the beginning of the term. Payments are to be submitted upon signing and reminder
notices for payment, NSF cheques or FREEZE is subject to a $20.00 Administrative Fee. Registration fees
of $99 per 1 year term clients must be paid upon contract signing. A FREEZE to the contract may ONLY be
applied if there is a medical note signed by an M.D. stating the date of the request, along with a return to
exercise (at the expense of the member). There is also an administrative fee of $20.00 for the FREEZE to
be applied and removed. The terms of the contract remain the same with a monthly fee being withdrawn
from the member’s account if a balance is owing and the maximum length of the FREEZE is 3 months which
will be added on to the end of the membership term once all required documentation has been returned.
11) HOLIDAY/CLOSURES & SHUT DOWNS- I understand that holiday closures and shut down days have been
included in GROUP TRAINING SCHEDULES. Closures due to unforeseen circumstances will not be
refunded.
12) BUYER’S REMORSE/CANCELATION POLICY-I understand that the seller reserves the right to assign this
contract and the right to resolve payments under this contract. The member acknowledges he/she has read
and understands the waiver. Our cancellation policy allows all memberships and personal training packages
to be cancelled within 10 days of purchase with a full refund. After the 10th day you may not cancel this
contract.
13) PRIVACY POLICY- I understand that when you become a member at Revive Fitness, it is essential to
collect for operation of health provision. Information received via our web server automatically collects your
internet domain name or IP address, which may identify you depending on the “naming standards” followed
by your Internet Service Provider. This information is collected so that we know how many people visit our
site, the geographical region they are from, and which pages they view on our site. It is maintained in our
confidential statistical reports, so individuals are not identified, and it is never given or sold. If you use our
feedback form or contact us, you will be providing us with some personal information including your name,
email address and perhaps information about your personal circumstances. This personal information will be
used only to reply to your question. It will not be disclosed to any other office or individual outside Access
and Privacy Services.
14) CANCELATION/REFUND POLICY- I understand that Revive Fitness has the right to terminate membership
for default payment, delete all member content without written notice, for conduct that Revive Fitness
believes harmful to Revive Fitness’ business. If Revive Fitness feels the need to terminate the contract there
will be no refund of fees. This contract can be broken with 30 days written notice and paying a default fee of
25% on top of the balance owing, deposits will not be refunded.
15) SCHEDULES/CLASSES- In understand that Revive Fitness is a co-ed establishment and schedules and
hours for Group Training, Private, Team or Specialty training/classes may change with notice.
I, __________________________________________have read this Release and Terms of Agreement and
I understand all of its items. I sign it voluntarily and with full knowledge of its significance.
______________________________________
CLIENT
_________________________________________
TRAINER/REVIVE FITNESS REPRESENTATIVE
______________________________
DATE
_________________________
DATE
PRE-AUTHORIZED AUTOMATIC PAYMENT AGREEMENT
REVIVE FITNESS
Revive Admin Master Documents/NEW BUSINESS DOCUMENTS/Clients Forms/Section 6 – Client Forms/Membership contract
905-951-1219
12612 Hwy #50 – Suite 11A, Bolton, On L7E 1T6,
www.revivefitness.ca
admin@revivefitness.ca
MEMBERSHIP & TERM CONTRACT/REGISTRATION FORM
As a convenience to our clients, we offer the ability to automatically renew training agreements so you never have to worry about
losing your training rates, experiencing any disruption to your training workouts or having your account go into arrears and being
charged additional fees.
Name (Please print): ___________________________________________________________
Personal Training: I understand that I have purchased ______ Hrs of Private Training / Partner Training / Team Training / Nutrition
for $________. I hereby authorize Revive Fitness to deduct $________ from the below listed account at the beginning of the
session/package.
Initial:_____
Group Training: Note – Record additional family member names below.
1 Year Individual
1 Family Rate:
2 Family Rate
3 Family Rate
Youth
Total Rate Monthly
HST (13%)
Total Amount Deducted
from Account Monthly
$
$
$
I understand that I have agreed to a Group Training agreement for a ____________ term. I (we) hereby authorize Revive Fitness to
automatically deduct $________ from the below listed account every month beginning ________. My minimum term commitment
will expire on________ at which time my agreement will automatically renew on a month to month basis unless I provide 2 weeks
notice to discontinue this option.
Initial:_____
Revive Fitness staff have explained this agreement and collected $________ for any Initial Client Fees and any training fees due
before the next billing date.
Initial: _____
NOTE: Do not sign this Agreement before you have read and understand it completely. The Terms and Conditions stated on the reverse side are part
of this Agreement. YOU ACKNOWLEDGE THAT YOU HAVE READ AND RECEIVED A COMPLETED, SIGNED COPY OF THIS AGREEMENT (front
and back). You certify that you are 18 years of age or older OR your parent/ legal guardian has signed this agreement.
Client Signature___________________________________________________________ Date_________________
Guardian’s Signature (required for members 17 years and younger) _________________________ Date_________________
I agree to allow Revive Fitness to charge my account on a monthly term based on the information provided above.
Name on Credit Card: ___________________________________________________________________
Card #:___________________________________________ Expiry Date: ___________ Code: _________
Address of Credit Card Billing: _____________________________________________________________________
Street #
City
Signature: ________________________________________________
Prov
Date: __________________
Print Name: _________________________________________________
REVIVE FITNESS
Revive Admin Master Documents/NEW BUSINESS DOCUMENTS/Clients Forms/Section 6 – Client Forms/Membership contract
PC
905-951-1219