CROSSFIT NEW HAVEN MEMBERSHIP AGREEMENT
Client Name:____________________ Date of Birth:____________
Address:_______________________________________________
Email:_________________________ Phone:_________________
CrossFit New Haven membership details:
* Paid in advance of service on same day each month. The billing date will coincide
with the date the contract begins.
* Dues are paid by monthly automatic electronic payment (credit card, debit card, or
automatic checking account draft)
* Memberships are automatically renewed with the same terms at the end of the
membership period.
* Membership dues for month­to­month memberships may increase at anytime with
30 days notice.
* Reinstatement of past due memberships require payment in full of dues owed and
payment of the first month of the new membership.
* Listed prices do not include State sales tax which is collected on all memberships.
* Memberships may be placed on suspension (minimum of 1 month) for
documented eligible circumstances only (medical suspension, work travel or school
related travel).
* Written notice (letter or email) of five days must be given to assure
cancellation of membership and automatic payments. Verbal notice is not
accepted.
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MEMBERSHIP OPTIONS
(Check desired membership)
­­­ Automatic payment is required for all memberships­­­
*All fees subject to 6.35% CT sales tax*
On ramp:
5 PT sessions $300.00 ________
12 sessions $175.00 ________
Membership contracts (monthly auto pay):
Unlimited $160 ________
3x/wk $120 _______
3x/wk 3 month commitment $110 _______
*if you commit to 3 months you will be charged once a month for three months regardless of
membership status. At the completion of your three month commitment your membership will
automatically switch over to a month to month 3x/wk contract at the same rate of $110/mo. You
may switch to an unlimited membership at the end of the three month commitment as well. A
written termination is still required if you wish to terminate your membership after the three month
commitment.
Membership discounts:
Student 10% ________
Family/Spouse/Veteran 10% ________
First responder/Military 20% ________
*please note there are no membership discounts for the on ramp sessions. Your membership must
commence within 60 days after completing the on ramp or you will be asked to retake the on­ramp
program at the prevailing rate.
Other fees and charges:
Late fee/Declined/Insufficient Funds $15.00
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PAYMENT AGREEMENT
I agree to the following terms for membership at Crossfit New Haven:
­ The first payment (excluding sales tax), of $__________________.
­ The first automatic payment (excluding sales tax) of $__________ will be paid on _____________
and on the same day each subsequent month until membership is terminated.
­ I understand that membership dues are non­refundable, paid in advance of service and that my
membership will be automatically renewed at the end of each term at the current rate unless five
(5) days written notice of cancellation is provided to CrossFit New Haven. I also agree to pay
listed fees for late and/or declined payments.
Signature ______________________________________ Date_______________
AUTOMATIC PAYMENT AUTHORIZATION
Card number:___________________________________ Exp.____________
Verification code_________
or
Checking Account #_____________________ Routing #_________________
Client name_______________________________
Client signature___________________________ Date___________
Compliance with Rules:
Member shall abide by all membership and facility rules and regulations established by CrossFit
New Haven, which may be posted at the facility, provided in writing, or issued orally and which may
be amended from time to time in their sole discretion. Of CrossFit New Haven (collectively, "Rules").
I agree that improper or unauthorized use of the facility or violation of the Rules may result in
member suspension or cancellation at CrossFit New Haven's Discretion.
General: This agreement, the Release and the Rules represent the complete understanding
between Member and CrossFit New Haven. No representations, written or oral, other than those
contained in this contract are authorized or binding upon CrossFit New Haven. member understands
the he/she is obligated to pay the membership fee regardless of whether the member uses the
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facility. Member agrees to promptly notify CrossFit New Haven in writing one any changes of
address, phone, and/or bank account/credit card information. At the end of the term of this
membership contract, it shall continue in effect on a month to month basis unless new rates have
been installed or you provide written notice of termination.
Miscellaneous: Photo/Video Release: I hearby grant CrossFit New Haven permission to use my
photograph/video image in any and all publications for CrossFit or Crossfit New Haven, including
website entries, without payment or any other consideration in perpetuity. I hereby authorize
CrossFit New Haven to edit, alter, copy, exhibit, publish or distribute all photos and images. I waive
the right to inspect or approve the finished product, including written or electronic copy, wherein my
photo appears. Additionally, I waiver any right to royalties or other compensation arising or related
to the use of the photograph or images.
BUYER’S RIGHT TO CANCEL:
If you wish to cancel this contract, you may cancel by mailing a written notice by certified
or registered mail to the address specified below. The notice must say that you do not wish
to be bound by this contract and must be delivered or mailed before midnight of the third
business day after you sign this contract. After you cancel, the health club may request the
return of all contracts, membership cards and other documents of evidence of
membership. The notice must be delivered or mailed to:
CROSSFIT NEW HAVEN, 1175 STATE STREET, NEW HAVEN, CT., 06511,
KARIN@CROSSFITNEWHAVEN.COM
You may also cancel this contract if you relocate your residence further than twenty­five
miles from any health club operated by the seller or from any other substantially similar
health club which would accept the obligation of the seller. This contract may also be
cancelled if you die, or if the health club ceases operation at the location where you
entered into this contract. If you become disabled, you shall have the option of (1) being
relieved of liability for payment on that portion of the contract term for which you are
disabled, or (2) extending the duration of the original contract at no cost to you for a
period equal to the duration of the disability. You must prove such disability by a doctor's
certificate, which certificate shall be enclosed with the written notice of disability sent to
the health club. The health club may require that you be examined by another physician
agreeable to you and the health club at its expense. If you cancel, the health club may
keep or collect an amount equal to the fair market value of the services or use of facilities
you have already received.
I certify that I have read and understand all of the terms of this agreement and agree to abide by all
of the terms of this agreement.
Member (please sign) _____________________
Date_______________________
CrossFit New Haven
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RELEASE FROM LIABILITY AND ASSUMPTION OF RISK (ADULT)
PLEASE READ CAREFULLY, COMPLETE, AND INITIAL EACH PARAGRAPH BEFORE SIGNING
I, _________________ __________________, have applied to CrossFit New Haven’s CrossFit based exercise
training program (the “Program”) at CrossFit New Haven’s facility located at 1175 State Street, Unit 201,
New Haven, CT 06511.
_____ I hereby acknowledge that I should consult with my physician before beginning any exercise
program.
_____ I certify that I am not aware of any medical condition which would render me unfit to participate in
any exercise program and that I will inform CrossFit New Haven immediately of any change in my
medical condition.
_____ I agree that if I experience symptoms such as shortness of breath, chest pain, unusual fatigue,
dizziness or fainting, or extreme pain, whether or not I am under the direct supervision of my trainer, I
will immediately stop exercising and inform a representative of CrossFit New Haven of my symptoms.
_____ I authorize any representative of CrossFit New Haven to obtain emergency medical treatment for
me, including transportation to a hospital or other medical facility.
_____ I UNDERSTAND AND ACKNOWLEDGE THAT THERE ARE RISKS INHERENT IN ANY EXERCISE PROGRAM
INCLUDING BUT NOT LIMITED TO HEART ATTACK, STROKE, ORTHOPEDIC INJURY, INJURIES CAUSED BY THE
USE OF EXERCISE EQUIPMENT AND OTHERS. THESE INJURIES CAN OCCUR SUDDENLY AND WITHOUT
WARNING, AND MAY RESULT IN DEATH. I AM VOLUNTARILY PARTICIPATING IN THIS TRAINING PROGRAM
WITH KNOWLEDGE OF THE DANGERS INVOLVED, AND I HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF
INJURY OR DEATH, AND VERIFY THIS STATEMENT BY PLACING MY INITIALS ABOVE.
_____ FOR AND IN CONSIDERATION OF PERMITTING ME TO PARTICIPATE IN THE PROGRAM, I, FOR MYSELF
AND FOR MY HEIRS, BENEFICIARIES, AND PERSONAL REPRESENTATIVES, HEREBY RELEASE AND FOREVER
DISCHARGE CROSSFIT NEW HAVEN AND ITS DIRECTORS, OFFICERS, MEMBERS, MANAGERS, EMPLOYEES,
AGENTS, ATTORNEYS, INSURERS, SUCCESSORS, AND ASSIGNS (COLLECTIVELY, “CROSSFIT NEW HAVEN
PARTIES”), FOR ANY AND ALL CLAIMS, DEMANDS, DAMAGES, LOSSES, LIABILITIES, RIGHTS, ACTIONS, CAUSES
OF ACTION, EXPENSES, AND SUITS OF ANY KIND WHATSOEVER, FORESEEN OR UNFORESEEN, FOR PERSONAL
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INJURY, WRONGFUL DEATH, DAMAGE TO PROPERTY, OR OTHERWISE RESULTING FROM MY
PARTICIPATION IN THE PROGRAM AND/OR THE ACTS OF OMISSIONS OF ANY OF CROSSFIT NEW HAVEN
PARTIES, INCLUDING ANY AND ALL NEGLIGENT ACTS, WHETHER ACTIVE OR PASSIVE, IRRESPECTIVE OR
WHETHER SUCH INJURIES, DEATH, OR DAMAGES OCCURE DURING TRAINING OR THEREAFTER.
_____ I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AT LEAST 18
YEARS OF AGE. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN ME AND
CROSSFIT NEW HAVEN AND I SIGN IT OF MY OWN FREE WILL.
Executed on ______________, ____________ at________________________, Connecticut.
___________________________________________________________________________ Signature
________________________________________ _______________________________ Print Name Phone
Number
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HEALTH HISTORY INFORMATION:
NAME: _________________________
Today’s Date___________
ADDRESS: _____________________
Date Of Birth___________
____________________
Age______
____________________
Gender: Male/Female
PHONE #: (HOME) _______________
Email:____________
(CELL) ________________
Position___________
(WORK) _______________
Company_________
Please answer the following questions:
Total Cholesterol #______ (it is highly recommended to have an annual screening)
Diagnosed hypercholesterolemia (>than 200 mg/dl or HDL less than 35 mg/dl)
YES/NO
Diagnosed hypertension? (Blood pressure > 140/90 mg/dl)
YES/NO
Do you smoke tabacco products?
YES/NO
Cardiac History (COPD/Heart Attack/Emphysema)
YES/NO
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Diabetes (Type 1 or Type II)
YES/NO
Any family history of heart disease prior to the age of 55.
YES/NO
Drinking habits (alcohol) How much per week?________
YES/NO
WOMEN: 55 years of age or older?
YES/NO
MEN: 45 years of age or older?
YES/NO
List any medications or allergies:_______________________________________________________
List any and all surgeries, illnesses or injuries (ortho) that you have had or currently have:
__________________________________________________________________________________
When was your last physical? __________________________
Please answer the following questions (please check all that apply):
Any heart/vascular problems:
Any Metabolic disease:
_____ Heart Disease, heart attack, angina
_____ kidney disease
_____ Coronary Angioplasty/cardiac surgery
_____ Thyroid disorders
_____ Rapid Heartbeats/palpitations
_____ liver disorders
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_____ Peripheral vascular disease
Any respiratory disease:
_____ Stroke
_____ Asthma
_____ Faint or dizziness
_____ Chronic bronchitis
_____ Shortness of breath
_____ Emphysema
_____ Ankle swelling
_____ Other
_____ Unusual Fatigue
_____ Chest discomfort at rest or during exertion
I verify that all information notes above are accurate. I understand that it is my responsibility to
update the staff of CrossFit New Haven of any changes in my medical status and it is also my
responsibility to obtain medical clearance from my physician if needed to participate in my personal
training program.
Signature of Participant__________________________________________
Date_________________________________________________
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EMERGENCY CONTACT FORM
NAME: _________________________________ TODAY’S DATE: _______________
EMERGENCY CONTACT IN CASE OF AN ACCIDENT:
NAME OF CONTACT PERSON __________________________________________________
PHONE # (HOME) _______________________________ (WORK) ______________________
RELATIONSHIP TO CLIENT ____________________________________________________
NAME OF CONTACT PERSON __________________________________________________
PHONE # (HOME) ______________________________ (WORK) _______________________
RELATIONSHIP TO CLIENT ____________________________________________________
DATE OF BIRTH: ______________________________AGE: __________________
ARE YOU ALLERGIC TO ANY MEDICATIONS: __________________________________
ARE YOU TAKING ANY MEDICATIONS AT THIS TIME: ________________________________
CHOICE OF HOSPITAL YOU WOULD LIKE TO BE TAKEN: ____________________________
WHAT TYPE OF INSURANCE DO YOU HAVE: ______________________________________
SIGNATURE OF CLIENT______________________________
DATE_______________________
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