OTHER-GYM-130314 Page 1 of 2
Gym Membership Application PAGE 1 OF 2
Nominated Gym: Western Hall Gymnasium
University Hall Gymnasium
Resident Name:
Home Address:
Emergency Contact Person:
Please indicate if you suffer from or have recently suffered any of the following conditions: *
Any heart or stroke conditions Yes No Diabetes Yes No
High blood pressure Yes No Hernia Yes No
Pain or tightness in the chest Yes No Epilepsy or fits Yes No
Difficulty in breathing or chronic cough Yes No Fainting attacks Yes No
Stomach or duodenal ulcer Yes No Back problems Yes No
Liver or kidney condition Yes No Asthma Yes No
* If you have answered Yes to any of the above, for your own safety, you are required to provide a medical certificate before utilising the gym.
Have any family members (including grandparents, parents, siblings) had heart problems prior to age 60?
Yes No
If yes, provide details:
Have you ever had any injury, illness, back or joint condition that may be aggravated by vigorous exercise? Yes No
If yes, provide details:
Have you had any surgery in the last six (6) months? Yes No
If yes, provide details:
Are you taking any prescribed medication? Yes No
If yes, provide details:
Do you have any other medical conditions that should be made known? Yes No
If yes, provide details:
Do you exercise regularly? Yes No
Are you pregnant? Yes No
OTHER-GYM-130314 Page 2 of 2
Membership Conditions PAGE 2 OF 2
A gym membership fee of $50.00 applies;
Membership fees are to be paid upfront and in full;
Memberships are non-transferable between Halls;
No refunds will be given on memberships;
Members must sign-in and out when utilising 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 it’s 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 behaviour and swearing will not be tolerated;
Do not allow entry to non-members;
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 your Hall office.
Indemnity and Release
Nominated Gym: Western Hall Gymnasium
University Hall Gymnasium
Resident Name:
Declaration and Waiver:
1. I realise that participation in exercise carries some risk. I hereby certify that I am aware of no medical conditions (except any
already noted herein) that may increase my risk of illness or injury due to an exercise program. I have read and understand
this questionnaire and hereby exempt, release and discharge the JCU Halls of Residence, it’s servants, agents and
contractors, from liability for any injury, as a result of my participation in any future program.
2. I, the undersigned, in consideration of, and as a condition of, acceptance of my entry to the gym, for myself, my heirs, my
executors and administrators, waive all and any right or cause of action which I or they might otherwise have arising out of
the loss of my life, or injury and damage, or loss of any description whatsoever which I may suffer.
3. This waiver, release and discharge shall operate separately in favour of all persons, corporations and bodies involved or
otherwise engaged in the operation of the nominated gym at JCU Halls of Residence, or servants or representatives of them.
Signature: Date:
Office Use Only
Joining Date: Membership Period: Semester Year FOB Activated:
Paid/Receipt Number: Charge Applied: Initials:
Medical certificate required? Yes No Medical certificate provided? Yes No
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