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Recreation Services
Vaughan Fitness Membership Application
All members or guests must complete this form prior to using the fitness centre. All information is confidential.
New: For new and previous members who have let their membership lapse 3 months or more. Complete Sections A, B, C & D.
Renewal: For all current renewals. Complete section A & C only.
Note: If address has changed, complete Section B. If medical information has changed complete Section D.
Section A: Client Information
First Name: Last Name:
Main Phone #: Cell Phone #: Other Phone #:
Full Address:
Email Address:
Check box to receive email updates. You can unsubscribe at any time.
Date of Birth: Age:
Emergency Contact: Main Phone #:
Name of Physician: Main Phone #:
How did you hear about us?
A free fitness consultation and program design is available to all 3-month and annual members. It is strongly recommended that members take
advantage of this professional service before beginning an exercise program. To book an appointment please speak to fitness staff.
Section B: Waiver Please read carefully and sign below
I hereby release the Corporation of the City of Vaughan and its employees from any and all claims or any damages whatsoever arising out of any
accident or injury which may be caused by or results from my participation while engaging in activities at or sponsored by any of the City of Vaughan’s
community centres; except where the damage or injury is caused by the negligence of the City of Vaughan or its agents, officers and employees
acting within the scope of their duties. I further agree that I, the undersigned, have no knowledge of any physical illness or disability that through my participa-
tion could prove dangerous or hazardous to my health.
I have been provided with a complete list of membership privileges and fitness centre policies and agree to abide by them.
Client Initials ___________
I understand that staff are on duty during all operating hours, though there may be times when staff is unavailable for direct supervision in the fitness centre. I am
aware that should exercise caution when using fitness equipment and/or engaging in a fitness activity I am unfamiliar with.
The City of Vaughan reserves the right to suspend or revoke any fitness membership in the event of inappropriate behaviour and/or failure to
follow fitness centre policies by the member and/or member’s guest.
Personal information on this form is collected pursuant to the Municipal Act, 2001, S.O. 2001 c.25, as amended and will be used for the purpose of entering membership
information into the City’s registration system. Questions regarding this collection may be directed to the Director, Recreation Services, City of Vaughan, 2141 Major
Mackenzie Drive, Vaughan, Ontario L6A 1T1, 905.832.8500.
Client Signature: Date:
Parent Signature: Date:
(if applicant is under 18 years old)
Office Use Only:
Member Guest Locker Rental:
Membership Type: Membership Number: Expiry Date:
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Section C: Physical Activity Readiness Questionnaire (PAR-Q)
Please read the following questions carefully and answer each one honestly. Check ‘yes’ or ‘no’.
1. Has your Doctor ever said that you have a heart condition and that you should only engage in exercise
prescribed by a Doctor?
Yes No
2. Do you feel pain in your chest when you engage in physical activity? Yes No
3. In the past month, have you had chest pain when you were not doing physical activity? Yes No
4. Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No
6. Is your Doctor currently prescribing drugs (i.e. water pills) for your blood pressure or heart condition? Yes No
7. Do you know of any other reason why you should not engage in physical activity? Yes No
‘Yesto One or More Questions:
The Doctors Consent Form (below) must be completed and signed by your
Doctor before you return this form to the fitness centre. Inform your Doctor
about the PAR-Q and questions you answered ‘Yes’ to. Doctor’s consent is also
required for pregnant women upon becoming a fitness centre member.
‘No’ to All Questions:
If you answered ‘No’ honestly to all the PAR-Q questions, you can be
reasonably sure that you can:
Start becoming much more physically active. Begin slowly
and build up gradually.
b) Continue with your present exercise program.
Client Signature: Date:
Parent Signature: Date:
(if applicant is under 18 years old)
Physician’s Physical Activity Consent
Physician’s consent is only required for:
a) anyone who answers ‘yes’ to any question on the PAR-Q.
b) pregnant women
Patient’s Name:
“I examined the individual named above and know of no reason to limit the patient in the use of the fitness centre facilities. These include
swimming pools, treadmills, bikes, rowing machines, stair climbers, elliptical trainers, track, squash and racquetball courts, weight training
equipment, sauna and whirlpool. I understand that upon request by the member, a fitness assessment consisting of stepping up and down
a series of stairs without exceeding 80% of maximum predicted heart rate, in addition to other strength and flexibility can be performed.”
Without restriction With the following restrictions: Only after I’ve been contacted
by fitness centre staff.
List any medication(s) taken by the patient and indicate the drug(s) effect(s) on heart rate and blood pressure at rest and during exercise:
Doctor’s Name: Signature: Date:
Address: Phone #:
Vaughan Fitness Membership Application (continued)
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