Recreation Fitness Center Application Form printable pdf download

For Office Use Only:

Please Initial

Frank Brown Recreation Fitness Center

Data Entered: _____

Photo ID Taken: _____

Date Entered: _____

Payment Received: _____

Application Form

The Frank Brown Recreation Fitness Center is open to citizens who live or work within the city limits of

Auburn. A $25.00 fee will be charged for a facility access/identification card and replacement cards will also

cost $25.00. The use of the fitness center is non-transferable and can only be used by the card holder.

Children ages 16-18 years must be accompanied by a parent or legal guardian; anyone under the age of 16 is

not allowed membership.

Today’s Date: _______________

Card Number: ______________

First Name: ____________________________

Last Name: ____________________________

Birthdate: _______________

Address (NO P.O. Box): ___________________________________________________________________

City: ____________________

State: _______

Zip Code: _______________

Home Phone: ____________

Cell Phone: ____________

Work Phone: _______________

E-Mail: ______________________________________________________________________

If you do not live in the City of Auburn, please list your place of employment: __________________________

Emergency Contact: ___________________________________

Relationship: _____________________

Emergency Phone: ____________________________________

I agree to abide by the facility rules and conditions and to treat with respect the facility and equipment and

the rights of other people using both.

_____ I received a copy of the Fitness Center Rules. (Please Initial)

WAIVER AND RELEASE OF ALL CLAIMS

I attest that I am physically healthy enough to use the equipment in the fitness center. I recognize and

acknowledge that there are certain risks of physical injury arising from the use of the fitness center and I

agree to assume the full risk of any injuries, damages, or loss which I or my ward may sustain as a result of

using the fitness center.

I do hereby waive, release and discharge the City of Auburn, its officers, agents, servants, representatives,

employees, and board members from any and all claims for injuries , damages, or loss which I or my ward

may sustain or which may accrue to me or my ward arising out of, connected with, or in any way associated

with my or my ward’s use of the fitness center.

I further agree to indemnify, hold harmless, and defend the City of Auburn, its officials, agents, servants,

Representatives, employees, and board members from any and all claims for injuries, damages or loss

sustained by me or my ward arising out of , connected with, or in any way associated with my use of the

fitness center.

In the event of an emergency, I authorize the City to secure from any licensed hospital, physician, and/or

medical personnel any treatment deemed necessary for my immediate care and agree that I will be

responsible for the payment of any and all medical services rendered.

I HAVE READ AND FULLY UNDERSTOOD THE ABOVE APPLICATION FORM, WAIVER AND RELEASE OF ALL

CLAIMS AND PERMISSION TO SECURE MEDICAL TREATMENT.

Signature: _________________________________ Date:_____________________________________

Signature of Parent or Legal Guardian if Under 19:___________________________________________

Recreation Fitness Center Application Form

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