Fitness Center Sign-Up First Name(Required) Last Name(Required) Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Membership type- Select all to be added to this membership. Single Membership $34.99+Tax/Month Add-On (Additional $27+Tax/Month) Spouses Name (IF ADDING TO MEMBERSHIP) First Last Spouses Date of Birth MM slash DD slash YYYY Gender Male Female Spouses Email Dependent #1 Name (If adding to membership. Must be a child between the ages of 12-21) First Last Add-On #1 Date of Birth MM slash DD slash YYYY Gender Male Female Add-On #2 Name (If adding to membership. Must be a child between the ages of 12-21) First Last Add-On #2 Date of Birth MM slash DD slash YYYY Gender Male Female Add-On #3 Name (If adding to membership. Must be a child between the ages of 12-21) First Last Add-On #3 Date of Birth MM slash DD slash YYYY Gender Male Female Add-On #4 Name (If adding to membership. Must be a child between the ages of 12-21) First Last Add-On #4 Date of Birth MM slash DD slash YYYY Gender Male Female RELEASE OF LIABILITY I, the undersigned, wish to participate in the activities and programs of Steadfast Fitness. I certify that I am physically able to participate in any activity I take part in and will use good judgment while exercising. I recognize that I am responsible for knowing my own state of health, and I will advise the facility staff of any health problems related to exercise. I also understand I may be denied participation in activities for health reasons at the discretion of the staff. I, the undersigned, so accept any and all responsibility and assume all risk of any injury or damage to my person that may arise, whether directly or indirectly as a result of my participation in the program of Steadfast Fitness. I hereby release and discharge Steadfast Fitness and its respective officers and employees from all claims, damages, and liability whatsoever that may result from my injury or death, accidental or otherwise, during or arising from my utilization of the activities of Steadfast Fitness. I agree to abide by the rules and regulations of Steadfast Fitness with the understanding that violation of such rules may result in withdrawal of my privileges to use the facility or participate in the programs offered. I certify that I have read and that I understand the contents of this waiver.(Required) YES I AGREE & ACCEPT(Required) YES I AGREE & ACCEPT FOR ALL OTHERS ADDED TO MEMBERHIPInitial to Confirm AUTOMATIC CREDIT CARD AUTHORIZATION: Billing of Monthly Dues: By signing this agreement, you have authorized Steadfast Fitness to bill your debit or credit card for your monthly dues. Your authorized account will be billed on or shortly after the 15th of each month beginning on the next 15th of the month. A $10 service charge will be applied for each month your monthly dues are returned uncollectible. • Your membership will continue on a month-to-month basis. • In order to cancel the billing of the membership fee that occurs on or about the 15th each month, Steadfast Fitness requires 30-day cancellation notification in certified mail or by email. • Steadfast Fitness reserves the right to cancel memberships over 60 Days delinquent.(Required) YES I AGREE & ACCEPTConsent(Required) YES I understand I will be billed a prorated amount from todays date until the 14th of the next month.(Required)Initial to Confirm NOTICE TO BUYER: Do not sign this contract unless you have read it all. Also, Do not sign this contract if it contains any blank spaces. You may cancel this transaction in writing anytime prior to midnight of the third business day after this transaction. Steadfast Fitness and the undersigned member agree as of this date to the following membership contract as described in the comprehensive list of programs. As a buyer of this membership plan, I. Steadfast Fitness, LLC, (hereto referred to as Steadfast Fitness) will: a. Refund you the pro-rated cost of any unused services, within 15 days after request thereof, if: i. You are unable to receive benefits from our services by reason of death or disability. We may require that the disability be confirmed by an examination of a physician agreeable to you and us; provided, however, that this subparagraph shall not operate to prevent you from providing the disability in a judicial proceeding. Or, ii. Steadfast Fitness is relocated more than 8 miles from its present location, or the services provided by us are materially impaired. b. Refund you the pro-rated cost of any unused services within 15 days after Steadfast Fitness ceases operation. c. Memberships can be frozen for medical reasons only. Freeze must be done at time of illness, injury or other medical condition. d. Reserve the right to discontinue any program at any time. e. If rates will be increased due to Steadfast Fitness population or usage, it will happen with at least a 30 day notice to all members. f. Cancellations are to be made in person or preferably by email at [email protected]. ALL cancellation requests will have a 30 day cancellation period from the date of submission. Cancellation by phone/fax will not be accepted. g. In order to change the billing account for the 15th, Steadfast Fitness requires the change by the 1st in writing, in person, or preferably by email, or certified mail. h. Annual & Semi-Annual Membership Fee is non-refundable. II. Upon the concurrence of any of the circumstances enumerated in paragraphs I. a., b., or c. of this section, you or your estate shall be relieved of any further obligation for payment under the contract not then due and owing. I have read the membership plan offered for sale by Steadfast Fitness, and the respective prices of the plan. I realize that all of the foregoing written material will be honored by Steadfast Fitness and understand my rights of not signing if there are any unfilled blanks, my rights of cancellation and refund policies as listed in the contract. I further realize that I must obey the rules of Steadfast Fitness, and that Steadfast Fitness has reserved the right to refund the pro-rated cost of any unused services and remove me from Steadfast Fitness at any time that my actions violate the rules of Steadfast Fitness. It is expressly agreed that all exercises shall be undertaken by me at my sole risk and that Steadfast Fitness, its owners, employees, and agents shall not be liable to me for any claims, demands, actions or causes of action whatsoever, to my personal property arising out of or connected with the use by me of the service and facilities of Steadfast Fitness. I do hereby expressly forever release and discharge Steadfast Fitness from all such claims, demands, injuries, damages, actions or causes of action. I have read and understand and voluntarily signed the foregoing Waiver and Release of Liability and Medical Release Form, and I have received a copy of this contract and release agreement. This constitutes the entire agreement between Steadfast Fitness, LLC, and the member.(Required) YES I AGREE & ACCEPTInitial to Confirm MONTHLY BILLING/CREDIT CARD INFORMATION(Required) Credit Card Expiration Date Credit Card Authorization Code (3 Digit Number on Back) Name on Card(Required) Billing Address (If different from application) Δ
