PLEASE PRINT CLEARLY

Full Name _____________________________________________________ Date of Birth (DOB)________________________ Age ________________

Social Security # ______________________________________ Driver’s License (State & #) ____________________________ Sex ____________

Local Address_____________________________________________________ City_________________________ State__________ Zip_________

Home Phone (___________)______________________ Business Phone (_________)__________________________________________

Employer____________________________________ Address_____________________________ City_______________ State_______ Zip________

In case of emergency treatment, please provide the following:

Current Medications _________________________________________________________________________________________________________

Known Medical Conditions ____________________________________________________________________________________________________

Known Allergies ____________________________________________________________________________________________________________

Emergency Contact ____________________________________ Relationship_________________________ Phone # (_________)________________

Name ______________________________SS#__________________ Relationship ________________________ DOB______________ Sex________

Membership Type: _______________________ Expiration Date: Staff’s Initials

Family Members to be included on Family membership:

Name ______________________________SS#__________________ Relationship ________________________ DOB______________ Sex________

PAR-Q

Yes No

_____________ ______________1. Has your doctor ever said you have heart trouble?

_____________ ______________ 2. Do you frequently suffer from pains in your chest?

_____________ ______________ 3. Do you often feel faint or have spells of severe dizziness?

_____________ _____________ 4. Has a doctor ever said your blood pressure was too high?

_____________ ______________ 5. Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been made aggravated by

exercise, or might be made worse by exercise?

______________ _____________ 6. Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?

_____________ ______________ 7. Are you over the age of 65 and not accustomed to vigorous exercise?

_____________ ______________ 8. Are you pregnant?

Please comment on any yes answer __________________________________________________________________________________________

1. In consideration of gaining membership or being allowed to participate in the activities and programs of Collin County Community College (CCCC) and to use its facilities, equipment, and machinery in addition to the payment of any fee or charge, I do hereby waive, release, and forever discharge CCCC and its officers, agents, employees, representatives, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in any activities or my use of equipment or machinery in the above mentioned facilities or arising out of my participation in any activities at said facility. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of CCCC or the use of any equipment at CCCC. Nothing in this release shall be construed to be a waiver of government or official immunity. (Please initial____________)

2. I understand and am aware that strength training, flexibility, and aerobic exercise, including the use of equipment, is a potentially hazardous act. I also understand that fitness and sport activities involve a risk of injury and even death and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death. (Please initial_____________)

3. I do hereby further declare myself to by physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in any of the activities and programs of CCCC or use of equipment or machinery except a s hereinafter stated. I do hereby acknowledge that I have been informed of the need for a physician’s approval for my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity, exercise, and use of exercise and training equipment so that I might have recommendations concerning these fitness activities and equipment use. I acknowledge that I have either had a physical examination and have been given any physician’s permission to participate, or that I have decided to participate in activity and/or use of equipment and machinery without the approval of my physician and do hereby assume all responsibility for my participation in activities and utilization of equipment and machinery in my activities. (Please initial___________)

Date:_____________________________________________________ Signature: _______________________________________________

Membership Waiver Form

PLEASE PRINT CLEARLY

Membership Type: ___________________________________ Expiration Date: ____________________ Staff’s Initials ____________

PAR-Q

Yes No

Membership Type: _______________________ Expiration Date: Staff’s Initials