Membership Contract
Date:__________________ Processed by: __________________
Last Name: ____________________________________ First Name: ____________________________________ Middle Initial: ________
Date Of Birth: _____ / _____ / _____
o New Member o Renewing Member o My contact information is the same. o I currently rent a locker.
Phones: (cell)_____________________________ (work)_____________________________ (home)______________________________
Mailing Address: _______________________________________________________________________________________________
City: ___________________________________________________________________ State: ______________ Zip: ______________
Email: _______________________________________________________________________________________________________
Emergency Contact: __________________________________________________________ Phone:______________________________
The undersigned hereby purchases a membership to the Kilpatrick Athletic Center at Bard College at Simon’s Rock on the terms and conditions set forth
below and promises to pay such membership in accordance with the payment terms set below: (check one)
Electronic Funds Transfer
4 weeks 3 months 6 months 12 months 6 months or more
Young Adult (16-20) o $ 40.00 o $105.00 o $180.00 o $315.00 o $ 35.00/mo
Adult (21-64) o $ 95.00 o $225.00 o $420.00 o $755.00 o $ 90.00/mo
Senior (65+) o $ 70.00 o $200.00 o $380.00 o $680.00 o $ 70.00/mo
Couple/Family o $170.00 o $340.00 o $505.00 o $850.00 o $105.00/mo
Locker Rental: (optional) 1/2 Locker o$ 50.00 o $ 75.00 o $125.00
(optional) Full Locker o$100.00 o $150.00 o $250.00
All Simon’s Rock alum/parents receive 20% discount off membership only.
All military, first responders, and law enforcement receive 20% discount off membership only.
• Members under 18 require parent’s or guardian’s signature—see our information and policies sheet for guest restrictions.
• Six months or more of EFT requires six month minimum contract, first month due at signing.
All memberships are non-refundable and non-transferable.
All memberships should be renewed two weeks prior to the expiration date.
All lockers are subject to availability. Lockers are paid in full only and no other discounts apply.
Signature: ______________________________________________________________________________ Date: __________________
Children’s Information
Members’ children under age 21 are included at no additional fee. Please see our information and policies sheet for supervision details.
First Name M.I. Last Name Date of Birth
________________________________________________________________________________________ _____ / _____ / _____
________________________________________________________________________________________ _____ / _____ / _____
________________________________________________________________________________________ _____ / _____ / _____
________________________________________________________________________________________ _____ / _____ / _____
________________________________________________________________________________________ _____ / _____ / _____
t continue to other side t
RESPONSIBILITIES
I am aware that the majority of Simon’s Rock students are under the age of eighteen and are, therefore, legally minors. I acknowledge that this places me in a role of adult
responsibility in any of my interactions with them and that inappropriate relations by myself, my family, or my guests could result in termination of my membership.
I am aware that all recreational activities entail some risk of injury or illness to myself or damage to my property, and I voluntarily accept all reasonable risks associated
with participation in Kilpatrick Athletic Center activities. I hereby represent that I am in good health and capable of participating in recreational and athletic activities at
the Center. In consideration of being permitted to use the Center, I (on behalf of my family, heirs, and personal representative(s)) release, discharge, hold harmless, and
covenant not to sue Bard College at Simon’s Rock, its trustees, officers, agents, employees, contractors, and any students acting as employees, with respect to any and
all liability for any harm, injury, damage, cost, or expense of any nature whatsoever which I or my property may incur while participating in Center activities. I further agree
to defend, indemnify, and hold harmless Bard College at Simon’s Rock, its trustees, officers, agents, employees, contractors, and any students acting as employees, to the
fullest extent permitted by law, from any and all damages, liability, actions, debts, demands, or expenses of any nature whatsoever, including attorneys’ fees, in the event of
personal injury or property damage sustained by any member, guest, or employee of the Center, if such injury or property damage is caused, in whole or in part, by the acts
or negligence of me, my family, or my guests.
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)
PAR-Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of PAR-Q is a sensible first step to take if you are
planning to increase the amount of physical activity in your life. For most people physical activity should not pose any problem or hazard. PAR-Q has been designed to identify
the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.
Common sense is your best guide in answering these few questions. Please read them carefully and check the correct answer opposite the question if it applies to you.
Y N
o o Has your physician ever said that you have a heart condition?
If yes, has your physician recommended only medically supervised activity? __________
o o Do you frequently have pains in your heart and/or chest?
o o Do you often feel faint or have spells of dizziness?
o o Do you have high blood pressure?
If yes, are you on medication? __________ What kind? _____________________________________________________________________
o o Are you on any other medications that would affect your heart rate or ability to participate in an exercise program?
o o Do you have elevated blood cholesterol?
o o Do you have any muscle, joint, or back disorder that could be aggravated by physical activity?
o o Are you over 65 and not accustomed to vigorous exercise?
o o In the past 12 months, have you had surgery or been treated for a serious illness/injury by a physician?
o o Are you aware through your own experience, or a doctor’s advice, of any other physical reason against your exercising without medical supervision?
If you answered YES to one or more of the questions:
We recommend that you consult with your personal physician BEFORE increasing your physical activity and/or taking a fitness test. Tell your physician what questions you
answered YES to on the PAR-Q, or take a copy to show them. Your physician may provide guidelines for your exercise program based on your medical history. After you
consult with your physician, we recommend that you schedule an appointment with our Fitness Director.
Signature: ____________________________________________________________________________________ Date: _______________________
t EFT MEMBERS ONLY t
ELECTRONIC FUNDS TRANSFER (EFT) AGREEMENT
If you choose the EFT payment option, you are required to pay the first month at signing.
By signing this agreement, you authorize Kilpatrick Athletic Center to bill your bank account or credit card for your monthly payments by EFT for six months or more
beginning the second month of your membership. If Kilpatrick Athletic Center is unable to collect your monthly payment for any reason, a $20.00 administrative fee and the
uncollected payment will be added to the following month with no further notice. If your monthly payments are delinquent for two consecutive months, the remainder of
your dues balance will immediately come due. If you cancel your membership prior to the minimum EFT term indicated above, the remainder of your dues balance will
immediately come due.
EFT CANCELLATION:
EFT membership dues are ongoing and will be collected for the minimum number of months indicated and will continue monthly until you submit a signed
and dated notice of cancellation in writing no later than the 15th of the month preceding the last full month of your membership.
Please bill my:
o Visa o MasterCard ___________ - ___________ - ___________ - ___________ Exp. ________ / ________ CSV: ________
o Checking Account Bank Name: _____________________________________________
Bank Routing Number: _________________________ Account Number: _________________________
Signature: ____________________________________________________________________________________ Date: _______________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome