APPLICATION FORM
POLEATES Pole and Pilates Studio
Membership Application:____________________________________________________________
Name:
Home Address:
Email:
Home Number:
Mobile:
Emergency Contact Person:___________________________________________________________
Name:
Relationship:
Home Number:
Mobile:
* Please indicate if you suffer from or have recently suffered any of the following conditions:
Any heart or stroke conditions: Yes
No
High blood pressure:
Yes
Pain or tightness in the chest:
Yes
No
Difficulty in breathing or chronic cough: Yes
Stomach or duodenal ulcer:
Yes
No
Liver or kidney condition:
Yes
Diabetes:
Yes
No
Hernia:
Yes
Epilepsy or fits:
Yes
No
Fainting attacks:
Yes
Back problems:
Yes
No
Asthma:
Yes
* If you have answered YES to any of the above, for your own safety, you are required to provide a medical
certificate before utilising the studio.
1/ Have any family members (including grandparents, parents, siblings) had heart problems before 60?
Yes/ No
If yes, provide details:
2/ Have you had any injury, illness, back or joint condition that may be aggravated by vigorous exercise?
Yes/ No
If yes, provide details:
3/ Have you had any surgery in the last six (6) months? Yes/ No
If yes, provide details:
4/ Are you taking any prescribed medication? Yes/ No
If yes, provide details:
5/ Do you have any other medical conditions that should be made known? Yes/ No
If yes, provide details:
6/ Do you exercise regularly? Yes/ No
7/ Are you pregnant? Yes/ No
No
No
No
No
No
No
Membership Conditions:______________________________________________________________________
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A one off fee of $49.00 applies to direct debit;
Membership fees are to be paid in full;
No refunds will be given on memberships;
Members must sign-in and out when utilising the PoleAtes Studio, using the sign-in book provided.
Gym Rules:_________________________________________________________________________________
I hereby agree to abide by all the rules and regulations of PoleAtes as listed below:
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Neat and clean clothing must be worn;
Equipment must only be used for it’s intended purpose;
Equipment must be returned to place of origin after use;
No use of equipment under the influence of alcohol;
No alcohol to be consumed in the studio;
Offensive behaviour and swearing will not be tolerated;
Do not allow entry to non-members;
Any breach of these rules may result in a monetary fine or suspension or cancellation of your membership.
For advice and/or induction please contact PoleAtes.
Indemnity and Release :_______________________________________________________________________
Declaration and Waiver:
PoleAtes
1.
2.
3.
I realise that participation in exercise carries some risk. I hereby certify that I am aware of no medical
conditions (except any already noted herein) that may increase my risk of illness or injury due to an
exercise program. I have read and understand this questionnaire and hereby exempt, release and
discharge the PoleAtes, it’s servants, agents and contractors, from liability for any injury, as a result of
my participation in any future program.
I, the undersigned, in consideration of, and as a condition of, acceptance of my entry to the studio, for
myself, my heirs, my executors and administrators, waive all and any right or cause of action which I or
they might otherwise have arising out of the loss of my life, or injury and damage, or loss of any
description whatsoever which I may suffer.
This waiver, release and discharge shall operate separately in favour of all persons, corporations and
bodies involved or otherwise engaged in the operation of the nominated studio at PoleAtes, or servants
or representatives of them.
Signature:
Date:
Office Use Only
Joining Date:
Paid/Receipt Number:
Medical certificate required? Yes No
Membership Period:
Processed Date:
Casual. Monthly, 6 Month, Year
Charge Applied:
Initials:
Medical certificate provided? Yes No
Direct Debit Request
POLEATES Pole and Pilates Studio
Please choose your monthly payment (place an X next to your desired option - only one):
12 month Contract $90 Per Month
6 Month Contract $100 Per Month
Other:
I/We;
Surname:
Given Name/s:
Postal Address:
Email:
Phone:
Request and authorise Poleates, subject to the Direct Debit Request Service Agreement (printed overleaf), to debit
any amount from my/our nominated account or card as follows:
BANK DETAILS - This will be debited on the same date every month
Name of Account:
BSB Number:
Account Number:
Financial Institution Name:
Suburb:
* Note: Direct Debiting is not available on the full range of accounts. If in doubt, please refer to your
Financial Institution.
CREDIT CARD DETAILS - This will be debited on the same date every month
Cardholders Name:
Card Number:
Expiry Date:
CCV Number:
ACKNOWLEDGEMENT_______________________________________________________________
By signing this Direct Debit Request I/We acknowledge:
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
having read and understood the Direct Debit Request Service Agreement (printed overleaf) and agree to
be bound by the terms of that agreement in addition to the terms of my Card Account; and
that this Direct Debit Request requests and authorises Poleates to debit amounts from my/our nominated
account or card each month
Signature: ............................................................................
Name:
Date:
OFFICE USE ONLY
Date Processed:
By Who:
DIRECT DEBIT REQUEST SERVICE AGREEMENT
1.
2.
3.
4.
This agreement authorises Poleates to withdraw money from your nominated account set out
in the Direct Debit Request form. If you have any enquiries relating to this agreement you
should contact Poleates.
Before you complete the Direct Debit Request form, you should confirm with your financial
institution that your nominated account can accept direct debits.The nominated account must
belong to you and every nominated account holder must sign the Direct Debit Request form.
If we want to change this Agreement, we will notify you within 14 calendar days in advance of
any change.
Please notify Poleates in writing if you want to:
• Make a change to this agreement
• Stop or defer an individual payment
• Cancel this agreement
5.
6.
7.
8.
If you want to dispute a debit that has been made from your nominated account, you should
contact us in writing immediately and we will respond to you within seven days.
If the debit date is on a weekend or public holiday in Sydney, we will process your payment on
the next business day.
You must make sure that sufficient cleared funds are available in your nominated account on
the payment date. If there are insufficient funds and your financial institution dishonours the
payment then refer to terms and conditions
We will keep your financial institution account details confidential. However, we will disclose
these details:
• If you consent; or
• To the extent required by law, for example if a court order requires disclosure; or
• For the purposes of this Agreement, for example, to settle a dispute.
9.
You indemnify and keep us indemnified against all losses, costs, damages and liability that we
suffer as a result of you giving us incorrect or false information in your Direct Debit Request.
Your indemnity:
• extends and covers all changes you make to your Direct Debit Request; and
• continues after this Agreement is ended.
MEMBERSHIP AGREEMENT AND TERMS AND CONDITIONS OF POLEATES
Pole and Pilates Studio
Welcome to PoleAtes. Before signing your PoleAtes Membership Agreement please take the time
to read the following terms and conditions of your membership. We advise you to only sign the
membership agreement if you understand and agree with these conditions. The information
outlined in these terms and conditions can / will be used in the event of a discrepancy.
1. INTRODUCTION
By signing the agreement you are agreeing to have been given a copy of this agreement and agree to
abide by the rules of membership. You also acknowledge and agree that you are medically sound to
undertake a normal course of exercise, you use the facilities at your sole risk and responsibility and you
are aware that exercise is physically demanding and participation in some activities may pose a risk to
your health. This agreement also relates to the member’s authority to PoleAtes to directly debit the
nominated bank account or credit card for any instalments or fees due under the terms and conditions
of this Agreement. These terms are stated below.
2. DEFINITIONS
In this Agreement unless the contrary intention appears:
1.
2.
3.
4.
The singular includes the plural and vice versa.
A reference to a party includes that party’s legal personal representative heirs and assigns.
“Member“ includes the parent or guardian of the Member if the Member is under 18 years.
” PoleAtes” means the PoleAtes named in the form of the agreement
3. RECEPTION AND ACCESS
All members must present their membership card (or photo ID) upon entry to the facilities at every
visit. The reception staff will scan your card registering your attendance. Card scan is compulsory for
security and insurance requirements. Card replacement cost is $5.00. Upon joining PoleAtes a photo
will be taken of you for security reasons relating to the safety of our members. The photograph will not
be used for any other purposes and will be stored on our database. All ‘guest visitors’ to PoleAtes are
required to present photo identification upon every visit.
4. DRESS CODE
Clothing must be clean and tidy with no offensive prints or designs for the consideration of other
members.
5. CHILDREN
Children under 14 years of age who are not members of PoleAtes are not allowed anywhere within our
club except for child minding facilities during normal supervised child minding hours (where
applicable).
6. USE OF EQUIPMENT
We ask that you return equipment to where you found them once you have finished with them.
7. LOST PROPERTY
We highly recommend that you use keep your belongings in a safe place. PoleAtes does not take
responsibility for loss or damage of your belongings. Any items of lost clothing will be held for two
weeks, and then donated to charity.
8. MEMBERSHIP
a. ENTITLEMENTS
Membership at PoleAtes Pole entitles you to:
i.
ii.
iii.
Workout as many times as you wish in a given period.
Participate in normally scheduled classes.
Use of exercise equipment located in the Pole Room.
b. OBLIGATIONS
Membership at PoleAtes requires you to:
i.
ii.
iii.
iv.
Comply with all PoleAtes rules.
Pay all agreed fees, ensure sufficient fees are available to cover all fees and advise us in
advance if your bank account or credit card is closed or changed.
Inform us in advance if there is any risk to your health if you participate in pole classes.
You acknowledge that it is your responsibility to cancel direct debit facilities in respect of
your membership when this agreement expires or is terminated.
c. SPECIAL CONDITIONS REGARDING MEMBERSHIP ENTITLEMENTS
i.
ii.
iii.
iv.
There are variations in the facilities and services provided at different PoleAtes venues. To
ascertain exactly what a particular club provides in addition to the above entitlements, please
enquiry at the club directly. There may be additional fees charged to access these facilities and
services.
PoleAtes reserves the right to make changes to equipment supplied in any of its clubs at any
time. PoleAtes also reserves the right to make changes to the Pole Timetable at any time. (ie.
alter class type, times and instructors).
All entitlements and entry into any PoleAtes is revoked if a member’s account is in arrears in
excess of $50.00.
If your automatic direct debit reverses or is returned to us by your financial institution we will
attempt to contact you about retrying the debit. If the debit remains outstanding it will be
processed within 14 days of the reversal with any reversal and late fees that apply. If you fail
to pay us the fees by the due date, we are entitled to refuse you entry to the club. If unpaid
fees remain outstanding, and after attempts by us to rectify the arrears your membership may
be forwarded to a collection agency for further action.
d. CHANGES TO CONDITIONS
PoleAtes reserve the right to change the conditions contained in Clause 8 by providing you with one
month advance written notice of any changes.
9. CANCELLATION / TERMINATION
This agreement is subject to a cooling off period (see Schedule entitled Specific and State Based
Conditions). A cancellation request should be directed to PoleAtes reception desk.
a. During Cooling Off Period:
In accordance with the Schedule entitled Specific and State based conditions your membership is
subject to a cooling off period and may be terminated under the following conditions:
i.
PoleAtes requires a written request to terminate the membership within the timeframe
specified as the cooling off period from the signing the membership agreement.
PoleAtes must receive a payment of $75.00 to cover administration costs.
PoleAtes may request an additional payment to recover costs in relation to any services
provided to the member within this period.
ii.
iii.
b. Outside Cooling Off Period:
Your membership may be terminated under the following conditions outside of the cooling off period:
i. Permanent Sickness or Physical Incapacity:
1.
2.
3.
PoleAtes requires a written request for termination advising the nature of the illness or
physical incapacity, outlining specifically how this prevents you from utilising any of the
services or facilities that PoleAtes is able to provide.
PoleAtes requires a medical certificate stating that you cannot utilise any fitness services or
facilities because of your permanent illness or physical incapacity.
Payment of 10% of the minimum membership fee or $75.00 (whichever is less)
ii. Termination for any reason (other than Clause 9 b. i. above)
1.
2.
3.
4.
PoleAtes requires that a Resignation Form be completed.
PoleAtes requires that the remaining balance of the minimum membership fee be paid to the
club in a one off payment as full and final settlement. (plus any outstanding fees owed to
PoleAtes).
The Minimum Membership Fee amount is written on the front of this contract.
In accordance with Clauses 9 b. i. 1-3, the Member may terminate this Agreement before the
expiry of the minimum term or payments only if all the instalments and fees due up to the date
of the expiry of the minimum term are paid. After the expiry of the minimum term or
payments, and after all instalments and fees due have been paid in full, should the box on the
front of this Agreement requesting termination at minimum term be marked then this
Agreement shall automatically terminate. Should the box on the front of this Agreement
requesting termination after the minimum term not be marked, then this Agreement shall
continue indefinitely until such time as the Member makes a request, after the expiry of the
minimum term for it to terminate. Any instalments/fees due at the date of termination
(including instalments/fees which fall due during the notice period) will remain a debt owed to
and recoverable by PoleAtes. The Member shall not consider that this Agreement has been
terminated until such time as this is confirmed in writing to the Member (not more than 14
days after the termination date). Termination of this Agreement will also terminate the Direct
Debit Request Authority.
iii. Termination of your membership once you have met the Minimum Membership Fee obligation.
You must:
1.
2.
3.
4.
Complete a PoleAtes Resignation Form.
Finalise any outstanding membership and/or collection fees.
Without exception, all final debits will consist of no less than the normal debit amount
In accordance with Clauses 9 b. iii. 1-3, there will be a period of notice of 30 days unless
otherwise specified by the Club between the date of request and the date of actual termination
iv. PoleAtes reserves the right to terminate this membership agreement in accordance with the
following conditions:
1.
2.
Failure to abide by any of the criteria listed in the Rules of Use.
Action upon a complaint by either a member or an employee (or contractor) of PoleAtes.
Payments due must still be paid in full. In the event that payments are being made by Direct
Debit, you should receive written confirmation of the termination within the 30 day period.
The Member shall not consider that this Agreement has been terminated until such time as this
is confirmed in writing to the Member (not more than 14 days after the termination date).
Termination of this Agreement will also terminate the Direct Debit Request Authority.
10. TRANSFER OF MEMBERSHIP BY THE MEMBER
A PoleAtes 6 or12 month direct debit membership, while within minimum term, may be transferred to
a non-member for a fee of $50.00. Transfers are subject to special criteria in addition to PoleAtes
normal membership guidelines.
11. DAMAGE & PERSONAL INJURY
To the extent permitted by law, PoleAtes excludes any liability to the Member in Agreement, tort,
statute or in any other way for any injury, damage or loss of any kind whatsoever (including, without
limitation, any liability for direct, indirect, special or consequential loss or damage), sustained by the
Member and/or any other person, or for any costs, charges or expenses incurred by the Member, arising
from or in connection with this Membership Agreement and/or the services/products provided by
PoleAtes, and/or any act or omission of PoleAtes.
12. SUSPENSION
Suspensions are available for a minimum period of 2 weeks and a maximum of 6 weeks per year. A
suspension form must be completed in person at the club at least 10 days before the period requested
and cannot be back-dated. A fee of $4.00 per week applies to suspend your membership and is payable
in advance on pre-paid memberships and non-direct debit clients. Direct debit clients will have their
suspension fees directly debited. Membership suspension fees do not contribute to the total minimum
membership fee.
13. PAYMENTS BY DIRECT DEBIT
If paying by Direct Debit the Member agrees to pay the instalment amount at the agreed payment
frequency until this Agreement is terminated in accordance with clause 9 above. Should there be any
arrears in payments the Member authorises PoleAtes to debit the outstanding balance in order to bring
the account up to date.
14. ADMINISTRATION FEE (DIRECT DEBIT)
If paying by Direct Debit, a one-off fee of $49.00 is payable to PoleAtes for administration purposes.
15. PRIVACY
A Customer’s “personal information” (as that term is defined in the Privacy Act 1988 (Cth)) will only
be used by PoleAtes to provide you with the services contemplated by this Agreement. PoleAtes
Privacy Statement can be obtained its website www.poleates.com.au.
16. CREDIT/DEBT REPORTING AGENCIES
If paying by Direct Debit, upon default by the Member in regard to any obligation under this
Agreement and failure to remedy the default after notification by PoleAtes, the Member authorises
PoleAtes to notify any debt collection/credit reporting agency of the default. Should this occur then at
PoleAtes’ sole discretion it may terminate the Agreement at which time the full outstanding balance for
the remainder of the minimum term or payments (including any current arrears) shall be due in full.
The Member authorises PoleAtes to add to the outstanding debt a fee of $50 and an amount equivalent
to 25% of the full outstanding balance (being PoleAtes expenses reasonably incurred in collecting the
debt) upon initial referral to the debt collection/credit-reporting agency.
17. INCREASE IN FEES
If paying by Direct Debit, PoleAtes may at any time AFTER the end of the minimum term, upon
sending written notice to the Member's last known address and giving 14 days notice, increase the
instalment amount. If the Member wishes to terminate this Agreement as a result of the increase in the
instalment amount, the Member must notify PoleAtes in writing within 14 days of the date of the
written notice sent by PoleAtes. The Agreement will be terminated upon receipt of this notice. If the
Member does not notify PoleAtes of its intention to terminate this Agreement within such specified
time period, then this Agreement will remain in force and the increase in the instalment amount will be
deemed to be accepted by the Member.
18. ENTIRE AGREEMENT
This Agreement, and Direct Debit Service Agreement (if paying by Direct Debit) constitute the entire
agreement, understanding and arrangement (express and implied) between the Member and PoleAtes
relating to the subject matter of this Agreement and supersedes and cancels any previous agreement,
understanding and arrangement relating thereto whether written or oral.
19. RISK WARNING
(a) PoleAtes warns that whilst you are on our premises using our services, you are at risk of suffering
physical harm or personal injury including broken bones, soft tissue injuries, joint injuries, permanent
disability or death. These injuries may occur from you:
(i)
slipping on wet flooring;
(ii) colliding with equipment, or other Members;
(iv) engaging in strenuous exercise and activities; or
(v) incorrect use of equipment or studio,
(b) You acknowledge that any such injury may result not only from your actions but from the action,
omission or negligence of others.
(c) You acknowledge and agree that the above mentioned injuries and potential causes of injuries are
not exhaustive, and there are other unknown or anticipated risks that may result in injury, illness or
death.
(d) You acknowledge that whilst every attempt is made to ensure that the recreational services and
facilities provided by PoleAtes are safe, there are some significant and inherent risks involved, and you
agree that you are participating voluntarily at your own risk and responsibility, thereby exposing
yourself to certain risks.
SCHEDULE – SPECIFIC AND STATE BASED CONDITIONS
NEW SOUTH WALES
Clause 9: In accordance with NSW Fair Trading (Health and Fitness Industry Code of Practice) your
membership is subject to a 7-day cooling off period
Please tick this box to certify you have read and understood the terms and conditions
By signing below, I certify that I have read, understand and agree to comply with all terms and
conditions set out in this agreement.
Signature ________________________
Name___________________________
Date____________________________