Membership form - Next Level Fitness

MEMBERSHIP AGREEMENTFirst Name: ______________________ M. Initial: _____ Last Name: ______________________Address: ________________________________________________________________________City: ___________________ State: _____ Zip Code: _______ DOB: __/___/___E-mail address: _________________________________________________________________Phone #: (_____)_____-_______ (m) (_____)_____-_______ (w)NEXT LEVEL FITNESS, LLC.P: (804) 909-5060 * F: (804) 217-6389barbara@next-levelfitness.comwww.next-levelfitness.com(_____)_____-_______ (h)Workout time of preference: __ 5:45 AM __ 9 AM __ 6 PM // T-shirt size: S M L XL 2XLWhat type of membership do you want? Choose one12-Month Plan: $60 per month 6-Month Plan: $70 per month Monthly Plan: $75 per monthI would like to make membership payment on _____ Annual or ____ Monthly basis.Membership cancellation policy:12 and 6-month memberships:_____ I understand written notice to cancel is required 30 days prior to renewal date_____ I understand that if I move out of town, a letter from my employer or other relevant document stating mymove will be requiredMonthly membership:_____ I understand that written notice to cancel is required by the 25 th day of the month preceding month ofcancellationChoose one billing method below & fill out appropriate box:1. Auto-pay monthly bank draft (EFT) – attach voided check.Name on Account: ____________________________________________________Bank name and branch: ________________________________________________Bank Routing #_______________________________________________________Account #: __________________________________________________________Signature: ______________________________________________

2. Name on Credit/debit card: _____________________________________________VISA/MC: __________-____________-__________-___________Exp Date: ____/____ /____ Zip code on cc billing address: ______Signature: ______________________________________________Payment policy:_____ I understand my monthly dues will be deducted in advance from my bank account or Visa/MC for theupcoming month on the 1st of each month._____ I will be responsible for any additional fees incurred due to insufficient funds at the time of billing._____ Balances still due after the 10th of the month will incur a $5 late fee.Emergency contact:First Name: ______________________ Last Name: ________________ _Phone #: (_____)_____-_______ (m) (_____)_____-_____ _ (w) (_____)_____-______ (h)Relationship: ____________________________________________________________________I have read and agree to the membership and payment terms above.___________________________________________Signature___________________________________________Print nameDate: ____/____/____NEXT LEVEL FITNESS, LLC.P: (804) 909-5060 * F: (804) 217-6389barbara@next-levelfitness.comwww.next-levelfitness.com

RELEASE AND HOLD HARMLESS AGREEMENTI, the undersigned, hereby certify that my participation in the NEXT LEVEL FITNESS, LLC (NLF) is entirely voluntary. Irepresent that I am in proper physical condition and am over 18 years of age and know of no reason why it would beunsafe for me to participate in this fitness program. In consideration of being allowed to participate in any way in thefollowing events and activities, I acknowledge, appreciate, and agree that:1. The risk of injury from the activities involved in any events provided by NLF staff is significant and includes, but is notlimited to, the following; drowning, near-drowning, sprains, strains, falling, fractures, heat stroke, other heat andcold injuries, over-use syndrome, injuries involving vehicles, animal bites and stings, contact with poisonous plants,acts of God, and the potential for permanent paralysis and death. These activities include, but are not limited to,paddling, climbing, biking, hiking, running, swimming, calisthenics, heavy lifting, ascending, traversing or rappellingfixed ropes, travel by boat, truck, car, or other convenience. While particular rules, equipment, and personaldiscipline may reduce this risk, the risk of serious injury does exist; and,2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THENEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my participation; and,3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, Iobserve any unusual significant hazard during my presence or participation, I will remove myself from participationand bring such to the attention of the responsible staff; and,4. I hereby release and discharge for all time NLF, their agents, officers, employees, instructors and participatingmembers, and if applicable, owners and lessors of premises used to conduct the event from all liabilities to theundersigned, or anyone representing the undersigned for any loss or damages, on account of any and all injury,disability, death or damage to person or property, or any resulting arbitration costs WHETHER ARISING FROM THENEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.5. I understand that I must rely on my own medical insurance in the event that I am injured while participating in theseevents.6. I hereby authorize NLF to use my name and picture for commercial purposes including but not limited to thewebsite, brochures, and flyers. I hereby waive the right to any and all payment or compensation for the use of mypicture.7. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITSTERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY ANDVOLUNTARILY WITHOUT ANY INDUCEMENT.Signature:________________________ Print name: __________________________ Date: ___/___/___NEXT LEVEL FITNESS, LLC.P: (804) 909-5060 * F: (804) 217-6389barbara@next-levelfitness.comwww.next-levelfitness.com