JLSCC Membership Application

APPLICANT INFORMATION

First Name *
Last Name *
Email *
Phone *
Alternate Phone
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

EMPLOYMENT INFORMATION

Current Employer *
Employer Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
How long? *
Phone *
Email *
Fax
City *
State *
ZIP Code *
Position *

EMERGENCY CONTACT

Name of a relative not residing with you *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone *
Relationship *

PLEASE INDICATE IF YOU SUFFER FROM OR HAVE RECENTLY SUFFERED ANY OF THE FOLLOWING CONDITIONS:

Any heart or stroke conditions: *
YesNo
High Blood Pressure: *
YesNo
Pain or tightness in the chest: *
YesNo
Difficulty in breathing: *
YesNo
Stomach or duodenal ulcer: *
YesNo
Liver or kidney condition: *
YesNo
Diabetes: *
YesNo
Hernia: *
YesNo
Epilepsy or fits: *
YesNo
Fainting attacks: *
YesNo
Back problems: *
YesNo
Asthma: *
YesNo

SPOUSE INFORMATION

Name
Phone
Alternate Phone
Email

REFERENCES

Name *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone *

CHILDREN IF MEMBERSHIP PRIVILEGES DESIRED

Name
Name
Name
Name

SIGNATURES

I authorize the verification of the information provided on this form is necessary. I have received a copy of this application.
Signature of applicant: *
Date *
Signature of spouse (only if for a joint membership):
Date
Membership Conditions - A gym membership fee applies. Please see attached fee schedule. - Membership fees are to be paid upfront and in full. - No refunds will be given on memberships. - Members must sign-in and out when utilizing the gym, using the sign-in book provided.
Gym Rules I hereby agree to abide by all the rules and regulations of the nominated Gym as listed below: - Closed in footwear must be worn. - Neat and clean clothing must be worn. - A towel must be used on all benches. - No chewing gum. - Gym equipment must only be used for its intended purpose. - Weights must be returned to place of origin after use. - Do not drop weights-place them down carefully. - No use of equipment under the influence of alcohol. - No alcohol to be consumed in gym. - Offensive behavior and swearing will not be tolerated. - Do not allow unauthorized entry to non-members. - No food or beverages allowed inside of gym area. 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 the office.
MEMBERS DECLARATION & PAYMENT DETAILS Before signing this document, I have read, understand and hereby agree to the terms and conditions of membership as defined in this membership form and know that it affects my legal rights. I agree to pay the following each month until I cancel my membership. (See Fee Schedule on weekly, monthly and annual cost off memberships). Cancellation of membership must be provided in writing to a staff member of the Jimmie Lee Smith Community Center at least 30 days in advance of requested cancellation date.

Please enter any two digits *Example: 12
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