Fillable Fitness Waiver Form printable pdf download

TOP NOTC H FITNESS A ND B OX ING

Waiver For m

Name___________________________________________________________Date: ____________________________

Address ________________________________ City, State ______________________________ Zip _______________

Cell # _____________________________________ (email) _______________________________________________

Gender __________ Age __________ Date of Birth_____________ Height ____________ Current Weight ___________

Emergency Contact Person ______________________________________Phone #_____________________________

PERSONAL HISTORY

Do you ever have any injuries, difficulties or problems during a high intensity exercise? __________ If so, please

Specify __________________________________________________________________________________________.

INJURIES

Please list any injuries that may prevent you in performing physical activity:

List: ____________________________________________________________________________________________.

TRAINING INTEREST AND GOALS

What goals do you have? ____________________________________________________________________________

Electronic Funds Transfer Agreement

You are hereby authorizing Top Notch Fitness and Boxing to electronically deduct your monthly dues from your bank or

credit card account. Dues are deducted on __________ of each month and are applicable to the following calendar

month. Deduction from your account will occur each month until you notify Top Notch Fitness in writing that you want to

cancel. Written notification must be received by Top Notch Fitness 10 days prior to renewal date. If Top Notch Fitness is

unable to collect your monthly dues for any reason $15 will be charged without further notice to you. If your monthly dues

payments are delinquent for more than 30 days your membership will be suspended until late fees are paid and

membership is up to date. The undersigned agrees to make payments on this membership at the agreed time regardless

of the amount that he/she uses the gym. If Top Notch Fitness cannot deduct your monthly dues from your account, Top

Notch Fitness may without notice to you increase a subsequent deduction for the dues previously uncollected. If the

uncollected dues were caused by insufficient funds (bank account) or insufficient credit (credit card account), a $15

service charge will be added. Top Notch Fitness sends you written notification twenty (10) calendar days prior to the first

day of the month for which the increased dues apply. Notice will be sent to your address according to Top Notch Fitness

membership records. It is your responsibility to make sure that Top Notch Fitness has your correct address on file. I

understand that membership agreement cannot be cancelled with exception of: The member becomes significantly

physically or mentally disabled with reasonable evidence of illness including doctor’s letter. The member may also cancel

if he/she moves their residence more then 25 miles outside training facility.

VISA / MASTERCARD / AMERICAN EXPRESS / DISCOVER CARD / DEBIT CARDS

EXPIRATION DATE

_________________________________________________________________________________________________

Signature

Date

Fitness Waiver Form