Fillable Membership Application Personal Information

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Membership Application Personal Information

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Membership Application
Personal Information
Member # __________________
Date (MM/DD/YYYY) __________________
First Name ( Mr./ Mrs./ Ms.) ________________ Middle Initial ____ Last Name _________________
Date of Birth (MM/DD/YYYY) _______________________ Age _______ Male Female Non-binary
Address _______________________________ City ___________________ State ______ Zip __________
Phone ____________________ Cell Home Email ________________________________________
County: Blount Jefferson Shelby St. Clair Tuscaloosa Walker Other _____________
Employed by __________________________ Retired from _______________________ Not Employed
Are you a Veteran? Yes No Branch of Service ____________________
Do you have a service connected disability? Yes No
Emergency Contact (Name) ____________________ Relation ______________ Phone _______________
Race/Ethnicity (Optional) Asian/Pacic Islander Black/African American Hispanic/Latino
White/Caucasian Native American Other
Referred By Member Physician Staff Name: ____________________________
Educator PT/Therapist Other ________________________
Primary Disability or Health Condition __________________ Secondary Health Condition ______________
Treating Physician (Name) ___________________________ Phone ______________ Fax _____________
Membership Package Options
Virtual $15/month Access to Lakeshore Online Fitness Live and On-Demand Classes
Standard $50/month Access to Lakeshore Online Fitness, Lakeshore facility, classes and programs,
excluding the Aquatics Center & aquatics classes
Premier $65/month Access to Lakeshore Online Fitness, Lakeshore facility, classes and programs,
including
the Aquatics Center & aquatics classes
Youth & Athlete $55/month Access to Lakeshore Online Fitness, Lakeshore facility, classes and
programs, including the
Aquatics Center & aquatics classes
Additional Individuals on Membership
Household members may be added: $25/adult, $20/child
Name _________________ Birth Date __________ Qualifying Condition (if applicable)
________________
Name _________________ Birth Date __________ Qualifying Condition (if applicable) ________________
Name _________________ Birth Date __________ Qualifying Condition (if applicable) ________________
Please note that all applications are reviewed to ensure members meet eligibility requirements.
Proof of residency for all members is required.
Membership Terms Name: __________________________
A. Duration of Membership:
Lakeshore membership is continuous for a minimum of one year and not transferable or refundable
after 30 days (see ‘Member’s Right To Cancel’ section below). After your rst year, membership will
automatically renew month to month.
B. Member’s Right to Cancel:
To cancel, written notice of your intent must be delivered or postmarked on or before the last day
of the month, and you must bring your account balance to zero. Members agree to pay charges
for goods, services and monthly dues, whether the facilities are used or not, until termination of
membership. Please mail, provide written notice handed in person, or email cancellation notice to:
membership@lakeshore.org.
Lakeshore Foundation
Attention: Membership
4000 Ridgeway Drive
Birmingham, AL 35209
C. Cancellation of Membership by Lakeshore Foundation:
Lakeshore Foundation reserves the right to immediately terminate the membership of any member
engaging in conduct in violation of this contract or the rules and regulations of Lakeshore Foundation.
D. Medical Conditions:
If you are unable to participate in programs for an extended period of time (one month or longer) due
to a medical condition, your membership may be placed in an inactive status after receipt of written
documentation from your physician. There will be no re-enrollment fee to reactivate your membership.
E. Continuous Membership:
Membership automatically renews each month after the rst year. If you cancel your membership or
allow it to expire, a re-enrollment fee may be charged and a new membership application must be
submitted.
_____ (initial)
Release and Indemnity
I hereby agree that all use of Lakeshore Foundation’s facilities, premises, programs and services
including transportation shall be undertaken at my sole risk and Lakeshore Foundation shall not be
liable for any injuries, accidents or deaths occurring to applicant, arising either directly or indirectly
out of utilizing Lakeshore Foundation’s facilities, services and programs, whether caused by the
negligence or other wrongful conduct of Lakeshore and any of its agents or employees. The
applicant for himself(herself) and on behalf of his(her) executors, administrators, heirs, and assigns,
does hereby expressly release, discharge, waive, relinquish, and covenants not to sue Lakeshore
Foundation, its ofcers and agents for all such claims, demands, injuries, damages or cause of
action, with respect to use of Lakeshore Foundation facilities, premises, programs and services which
the applicant may suffer or incur as a result of participation in such program, whether or not caused
by the negligence or wrongful acts of such persons or any agents, servants or employees of any of
them. I do further agree to indemnify and hold harmless each of them, of and from any and all claims,
demands or actions of any kind or nature whatsoever arising out of any injury or damages incurred
by the Applicant. In signing this release, I acknowledge and represent that I am over 19 years of age,
I am of sound mind, I have read this release, understand it, and sign it voluntarily, and that this paper
contains the entire agreement between myself and Lakeshore Foundation. The Applicant declares
that he(she) is physically able to participate in physical activity. Further, Applicant declares that
Lakeshore Foundation has advised him(her) to obtain a medical clearance if he(she) is unsure of his/
her physical health.
_____ (initial)
Past Due Accounts/Fees Name: __________________________
Membership must remain current to avoid cancellation and loss of privileges to the facility. A
statement will be sent at thirty (30) days for outstanding fees. After sixty (60) days, memberships will
be temporarily suspended until all fees are paid in full. After ninety (90) days, memberships will be
canceled. To rejoin at a later date, all past due fees must be paid as well as a $25 reactivation fee. A
fee of $25 will be charged for insufcient funds or returned checks. A $5 fee will be charged for lost
scan cards.
_____ (initial)
Audio/Visual Consent
I hereby consent and authorize the taking of photographs, movies, lms, videotapes, tape
recordings, or reproductions (collectively, “Reproductions”) of the persons who are hereby applying
for membership and consent to use, copyright, license, publication or broadcast of the same for
advertising, educational, promotional, or publicity purposes on the part of Lakeshore Foundation
and by its afliated and associated organizations, including its directors, ofcers, agents, servants
and employees. I hereby grant and assign to Lakeshore Foundation the right, title, and irrevocable
authority and interest to such Reproductions. I waive any and all claims for compensation and waive
any and all claims related to or arising out of the publication and dissemination of the same of any
lawful purposes. I further authorize the communication of information concerning the undersigned
in connection with the utilization of such Reproductions by Lakeshore Foundation and its afliated
or associated organizations, and their respective directors, trustees, ofcers, agents, servants
and employees without claim for compensation and waive all claims related to or arising out of the
publication and dissemination of the same.
_____ (initial)
Member Email Communication
We regularly provide information about our hours of operation, programs and services, education-
al content and other information aligned with and supporting our mission via email. By sharing your
email address you agree to receive these emails. You may opt out of these emails at any time by
using the “unsubscribe button” or contacting Member Services. Lakeshore never sells or shares your
information with external organizations or companies.
_____ (initial)
Program Evaluation/Research
I hereby consent and authorize the use of information I provide for use in program evaluation and
research where needed. I understand that my personal information will be kept condential and will
only be accessed by authorized staff.
_____ (initial)
Membership Agreement
Below are the signatures of all persons applying for memberships who are at least 19 years of age,
and signatures of guardians for all persons applying for membership who are less than 19 years of
age. I HAVE READ AND AGREE WITH THE TERMS OF THIS CONTRACT, and any questions were
answered to my full satisfaction. I will follow Lakeshore Foundation’s rules and regulations, amended
from time to time, and Lakeshore Foundation’s failure timely to enforce, in whole or in part, its rights,
privileges or powers under this contract shall not operate as a waiver thereof. I have received a copy
of this contract.
_____________________________________________________________
Member or Parent / Guardian Signature (if member is under 19 years of age)
Date ______________
(MM/DD/YYYY)
By using an electronic signature, you agree it is the legal equivalent of your
manual signature on this agreement.
_____________________________________________________________
Family Member Signatures (all members 19 years of age or over)
Date ______________
(MM/DD/YYYY)
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Physician Information
Lakeshore Foundation is dedicated to providing tness and recreation opportunities to individuals
with physical disabilities to assist them in living active, healthy lifestyles. In order to provide the most
comprehensive tness plan for each individual we request that a medical professional complete this form so
that the staff at Lakeshore is aware of any goals, contraindications or recommendations you may have.
Individuals are not permitted to pursue an exercise program at Lakeshore Foundation until we
receive this completed form from your ofce.
If you have any questions, please contact us at (205) 313-7400.
MD: _________________________________ DX. ____________________________
Patient Name: ____________________________________________
Patient Phone #:
__________________________________________
DOB (MM/DD/YYYY)
___________________
I, _________________________________wish to begin or continue an exercise program at Lakeshore
Foundation. Please complete the following:
Please list below any physical limitations or restrictions that might assist my instructors in
designing an exercise program specic to my needs.
I recommend that my patient become a participant in an exercise program with no restrictions
I recommend that my patient become a participant in an exercise program but urge caution due to
the following limitations / restrictions.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
I do not recommend that my patient participate in an exercise program.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Except as stated above, I am not aware of any consideration, which under ordinary circumstances would
interfere with this patient performing moderate level physical activity. He/she may exercise at his/her own
risk.
__________________________ ________________________ __________________
Physician Signature
M.D.
Ofce Telephone Number Date (MM/DD/YYYY)
4000 Ridgeway Drive • Birmingham, AL 35209 • www.lakeshore.org • Fax 205-313-7401
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Health History Date (MM/DD/YYYY) ____________
Name (please print) _________________________________ DOB (MM/DD/YYYY) ___________________
Check any of the following that apply to your health (currently or in the past): The information you provide
will help us develop an individualized plan to help you meet your goals.
Heart Condition - if yes specify
______________________________________________________________________________________
_____________________________________
High Blood Pressure or on Blood Pressure
Medicine
Cardiac Surgery - if yes, what kind and when
_____________________________________
Pain in your chest while DOING physical
activity
Pain in your chest while NOT DOING physical
activity
Diabetes Hypoglycemia (low blood sugar
Respiratory Disease (check all that apply)
Chronic Bronchitis Asthma Emphysema
Parkinson’s Disease
Multiple Sclerosis
Stroke – when and how affected
Arthritis (Type: Osteo Rheumatoid)
Ankylosing Spondylitis
Post-Polio Syndrome
Muscular Dystrophy
Ataxia
Morbid Obesity
Spinal Muscular Atrophy
Neuropathy
Lymphedema
Osteogenesis Imperfecta
Cerebral Palsy
Spina Bida
Epilepsy or Seizure Disorder
Head Injury date of onset ________________
Shunt where______________ date ________
Any other chronic medical condition
_____________________________________
Orthopedic Surgery – type and date
_____________________________________
Any bone or joint problems that limit you from
engaging in physical activity – if yes specify
_____________________________________
Currently Pregnant
Chronic Dizziness
Amputation - Type ______________________
Prosthesis Yes No
Spinal Cord Injury (date of onset)___________
Paraplegia Quadriplegia
Blind or Low Vision
Requires assistance with community mobility
Yes No
Incontinence of bowel or bladder
On a bowel management program
History of gastrointestinal (GI) issues such as
irritable bowel syndrome (IBS), C-diff, Crohn’s,
Colitis, etc.
Current pressure sore(s)
where ________________________________
Current open wound(s)
where ________________________________
Seizure in the past 6 months
date ___________________
Will a caregiver or family member be attending with you? Yes No
Do you use a mobility device to get around inside the home or in the community? Yes No
Manual Wheelchair Power Wheelchair Walker/Rollator Cane/Crutches Other ____________
List any information you would want shared with emergency personnel, including medications and allergies.
Functional Ability Classication Questions
Name: __________________________
Vision
Do you have difculty seeing, even if wearing
glasses?
No difculty
Some difculty
A lot of difculty
Cannot do at all
Prefer not to say
Don’t know
Hearing
Do you have difculty hearing, even if using a
hearing aid(s)?
No difculty
Some difculty
A lot of difculty
Cannot do at all
Prefer not to say
Don’t know
Mobility
Do you have difculty walking or climbing steps?
No difculty
Some difculty
A lot of difculty
Cannot do at all
Prefer not to say
Don’t know
Cognition (Remembering)
Do you have difculty remembering or
concentrating?
No difculty
Some difculty
A lot of difculty
Cannot do at all
Prefer not to say
Don’t know
Self-care
Do you have difculty with self-care, such as
washing all over or dressing?
No difculty
Some difculty
A lot of difculty
Cannot do at all
Prefer not to say
Don’t know
Communication
Using your usual language, do you have difculty
communicating, for example understanding or being
understood?
No difculty
Some difculty
A lot of difculty
Cannot do at all
Prefer not to say
Don’t know
Please choose one of these convenient payment options.
Name: _______________________________
Frequency of Payment:
I wish to pay my membership fees: Annually* Monthly
*10% discount is applied to all annual membership payments.
Donation to Lakeshore Foundation:
Yes, I would like to add $______________to my membership fees each month to support
scholarships for qualifying individuals to participate in Lakeshore Foundation programs.
Method of Payment:
Credit Card (Visa or MasterCard)
Debit Card (Visa or MasterCard)
Bank Draft from Checking or Savings Account (U.S. Banks only)
Automatic Payment Authorization
This payment authority is to remain in full effect until 30 days after Lakeshore Foundation has received
written notication from me (or either of us). I understand that termination of this agreement can only occur
if all transactions are resolved and my membership account is in good standing. I understand that fees will
be charged to (credit card), or debited from (debit card or bank draft) my account on the 2nd business day
of the month. I agree to pay $25 for each occurrence of a failed transaction due to insufcient funds in my
account.
Signature __________________________________________________ Date ____________________
Please provide a voided check.
Do not write your bank account or credit/debit card information on this sheet.
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Completed 23 February 2022

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