Courtney Medical Group – Club Level Application
A Private Health and Wellness Association
______________________________________________________________________________
INSTRUCTIONS FOR COMPLETING APPLICATION
Do Not Separate This Document—ALL Pages Must Be Returned.
This is a membership application that can be photo-copied for filling out the
registration. Please make as many copies as you need.
If you have children, and want them to join, each child must apply and pay
the $35.00 membership fee. Your child must write his or her name in the
appropriate space and sign below their printed name. If they can only print
their name, they must print in both spaces. Then a parent or legal guardian
must also sign in the appropriate space.
There's one inconvenience for which we must apologize in advance, but it is
necessary. A separate check or money order must be attached to each
individual application. (For example, husband and wife return two separate
checks and two separate applications. Family of four, return four separate
checks and four separate applications.)
In the lower left corner of each check (or the appropriate space on a Money
Order), you must write the two words “Membership
Dues” and you must print the name of the member after
the words “Membership Dues” (print only one member’s name
per check or Money Order).
• Make all checks or Money Orders payable to: Courtney Medical Group
• Mail checks and applications to: 533 Washington Ave, Pittsburgh, PA 15017
THE COMPLETED CONTRACT (ALL PAGES, including this one)
MUST BE RETURNED WITH ALL PAGES INITIALED in the
lower right hand corner.
Signature & Initials constitute agreement with all elements of this
contract.
Initial:_____
This private Membership Application is the property of The Courtney Medical Group
533 Washington Ave, Pittsburgh, PA 15017
Courtney Medical Group – Club Level Application
A Private Health and Wellness Association
______________________________________________________________________________
Contractual Offer by Applicant for Membership
In the year of our Lord, A.D; I being a man/woman/agent for minor, and being
self competent to engage in contract, have come to this private association seeking likeminded men and
women who have improved their health by education and experience of a science that has shown to be
effective for facilitating opportunity for the created body to exploit its own healing powers without the use
of synthetic (pharmaceutical) drugs and other chemical substances foreign to the human, created body.
I have performed my own due diligence and review of your organization to such
of my satisfaction and degree that I am confident in the value I will enjoy as a member of
your private organization, availing myself of all opportunities to improve my own living
experience. I do not seek nor solicit any treatment of present health conditions and/or
symptoms. I further understand that, if I experience any health conditions or symptoms
about which I have concerns, I can and will seek the advice and services of a medical
doctor.
I further attest to and affirm the following:
-I acknowledge and understand that no person or persons will be allowed
access to the facilities or products without each having a current paid
association membership and contract on record.
- I acknowledge and understand that there are annual, up-front monetary dues
of $ 35.00, associated with joining and maintaining this association and
organization, regardless of the date I join during the current calendar year.
- I further acknowledge that renewal of said annual fee of $ 35.00 is due on the
first day of the New Year, being January 1st A.D. and late after January 15th
A.D. Unless this annual membership fee is current, there is no access to the
building, staff, and product lines via any method of communications. If the
association card is lost or damaged a fee of $ 80.00 will be assessed to your
next visit to the association premises to cover replacement and re-enrollment
costs.
- I acknowledge and understand that there is no access to the secure facilities
and secure collaborative real time communications, etc., without showing the
proper and current association identification which is gained through the
annual association fees being up-to-date.
- I acknowledge and understand that if I have one or more minor children, each
child is eligible for membership under my guardianship. I am responsible for
payment of membership dues above described for each child I authorize to
become a member. I further acknowledge that compliance with all terms and
provisions of this agreement applying to the child member are my
responsibility as parent or guardian.
Initial:_____
This private Membership Application is the property of The Courtney Medical Group
533 Washington Ave, Pittsburgh, PA 15017
Courtney Medical Group – Club Level Application
A Private Health and Wellness Association
______________________________________________________________________________
- I acknowledge and understand that minor children under the age of (18)
eighteen coming for participation in association activities must be
accompanied by a parent or legal guardian who is a registered association
member.
- I acknowledge and understand, as stated herein before, the intent and purposes
of why I am seeking the health and spiritual education services available to
me as a member of this organization and I affirm that I am not here for any
medical diagnosis or treatment.
- I acknowledge and understand that this organization is a research, health, and
spiritual educational organization.
- I acknowledge and understand that membership benefits include the option to
privately acquire certain nutritional and organic products that may be devoid
of labels and therefore do not list contents or ingredients because most of the
products are proprietary, and may be mixed for the individual association
member according to his/her biological terrain requirements. I agree to refrain
from sharing these proprietary products with anyone not approved by this
association under contract, acknowledging that said products constitute a
“trade secret” subject to a perfected security interest. I further warrant that
until I have consumed the above described products, said products are
qualified collateral to which I hold as a debtor in possession.
- I agree and acknowledge that any and all products that I acquire and consume,
after my own study and examination of these products in the course of my
membership, are acquired “as is,” and that my acquisition of said products is
always executed under “caveat emptor” - - let the buyer assume full
responsibility for his choice and use of the item he acquires.
- I understand and am in full agreement that as a condition precedent to this
organization’s final acceptance of my application for membership on-site, I
must have a full “QHM® Evaluation” provided by the association for its
membership. Should my membership application be declined without
recourse or dishonor, the association will reimburse my $ 35.00 membership
dues tendered.
- I acknowledge and agree to give any and all requesting parties and authorized
representatives of this organization full disclosure of all nutritional products,
supplements, medications, and treatments I have taken or received in addition
those in use through this organization.
- I affirm and warrant that should, at any time during or upon expiration or
termination of my membership, I believe any other party within the
boundaries of this organization has failed to meet his or her obligation to me
in contract, or in the event of any allegation of breach made by me to that
effect, that I will submit my claim against that party to this organization’s
Executive Board, pursuant to the terms and conditions of the association’s
charter.
Initial:______
This private Membership Application is the property of The Courtney Medical Group
533 Washington Ave, Pittsburgh, PA 15017
Courtney Medical Group – Club Level Application
A Private Health and Wellness Association
______________________________________________________________________________
- I warrant and agree that my private membership in this organization is for the
purpose of facilitating my own growth and interaction with other members
and people of like-minded persuasion.
I acknowledge and agree to pay in full for all mutually agreed products and
services at the time they are rendered.
- I acknowledge that any member assumes full responsibility for his/her
nontransferable
user identification number and password (includes any internet
use) and assumes full responsibility for any and all unauthorized use of them
in any form or fashion.
Non-Disclosure and Privacy Contract
And Waiver and Disavow of Office or Agency
I have freely applied for membership under my inalienable rights in this
private association as a man or woman on the soil endowed by our Creator the LORD
God Almighty, bring with me no cloak of office, title, agency, or third party interest to
my activities while engaged as a private member of this association and private
organization. I warrant that if I am in the employ or service of any other corporate or
unincorporated organization, commercial, public, private and/or governmental agencies,
that my actions and decisions inside the boundaries of this organization are in an ultra
vires capacity vis a vis said foreign employer and/or agents aforementioned. I further
promise and warrant to keep any and all matters to which or about which I am directly or
indirectly informed or involved including, but not limited to, conversations, writings,
products, activities and identities of other members, officers or affiliated organizations
that I learn of through membership in this association as secret and confidential. I
understand that any and all parties, materials, products, techniques, and training, along
with all tangible and or intangible information to which I am exposed within the
boundaries of this association constitute a trade secret of the association itself and/or of
all the other members, officers, agents and/or representatives of this association and
organization. This contract constitutes a security agreement between myself as a member
and this organization, whereby when, and if, I obtain information such as that above
described I am holding said information and/or trade secret as a debtor in possession, and
should I disseminate the same in violation of the above terms I assume commercial
liability for my own breach and the actions of those to whom I disseminate said
information, who shall be jointly and severally liable as my agents and joint
tort-feasor(s).
Initial:_____
This private Membership Application is the property of The Courtney Medical Group
533 Washington Ave, Pittsburgh, PA 15017
Courtney Medical Group – Club Level Application
A Private Health and Wellness Association
______________________________________________________________________________
NOTICE TO THE PRINCIPAL IS NOTICE TO THE AGENT
AND NOTICE TO THE AGENT IS NOTICE TO THE PRINCIPAL
Finally, in the event of any and all actions on my part constituting a breach of the
above provisions and terms, I agree to fully indemnify this association, and any and all of
its current or past members, for one hundred and fifty percent [150 %] of all costs
incurred by this association and/or its members, officers, and/or agents in defending,
litigating, negotiating, and/or settling any and all claim(s) arising there from or to which
my breach is a contributing factor. I submit that any and all issues of fact shall be
determined by this organization’s Executive Board pursuant to the terms and conditions
of the association’s charter.
I offer, without any threat, duress, or coercion, the sum of $ 35.00 as
consideration for my application for association membership. I understand, warrant, and
attest that by my signing of this offer, that it is subject to acceptance or rejection by this
organization. All signers of this contract will be required to re-sign this or revised
contract in person and witnessed by an authorized business agent of Genesis Health and
Fitness Association if or when they visit our facilities. And also each witnessed member
signing will be video-taped and archived for security purposes. Every person is screened
for membership into this health association for final acceptance at our facility and maybe
required to submit additional health information at this screening prior to final
acceptance. All members are required to follow their designed health program. They may
be held in breach of this contract if it is not followed. Genesis Health and Fitness
Association reserves the right to alter, amend, change, or reject this contract at anytime
without due notice to the signing member and claims “Monocrat” status over this
contract at all times, as is also the “Creditor” and “Holder in Due Course” of this
contract. Should this organization reject my application, for any reason, I acknowledge
the association has done so without recourse or dishonor in any form or fashion.
END OF CONTRACT SECTION
________________________________________________________________________
ANSWER THE FOLLOWING QUESTION---PRINT CLEARLY
-------How urgent is your present condition------________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Initial:_____
This private Membership Application is the property of The Courtney Medical Group
533 Washington Ave, Pittsburgh, PA 15017
Courtney Medical Group – Club Level Application
A Private Health and Wellness Association
______________________________________________________________________________
Applicant’s Full Printed Name: ____________________________Date__________A.D.
Applicant’s Signature: _________________________Applicant’s Date of Birth________
Address: ______________________________________ City: _____________________
State: __________ Zip: __________Apt:#__________Applicant’s Age: _____________
Authorizing Parent or Guardian of minor: ______________________________________
(If applicant is under age 18)
Signature of Authorized Parent or Guardian:____________________________________
Home-Phone(s):____________________ Cell Phone(s):__________________________
E-Mail :__________________________Additional E-mail:________________________
PLEASE
Do Not Write Below This Line—Club Use Only
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The Above Applicant’s (Offeree’s) Signature is accepted for value this:
________ day of ______________________, 20____A. D.
Authorized Signature
For Genesis Health and Fitness Association: FORM
NUMBER G103-07
Print:__________________________Sign:__________________________
This private Membership Application is the property of The Courtney Medical Group
533 Washington Ave, Pittsburgh, PA 15017