Waiver & Registration Form

Referred by:

Contact Information

Name

Nick Name/Also know as:

Address

D.O.B

Email

Phone Number

Profile photo

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Emergency Contact

Emergency Contact Phone Number

GYM AT FULL CAPACITY - ALL NEW MEMBERSHIPS WILL BE ON WAITLIST UNTIL FURTHER NOTICE

Membership Options & Pricing
All prices listed are weekly costs - these can be paid weekly, fortnightly or four (4) weekly *couples unlimited cost is per couple ($80 weekly)

$50 :: Unlimited classes‎ $45 :: Whānau Unlimited (must reside at same address)‎ $45 :: 3 classes‎ $40 :: 2 classes‎ $40 :: Services Unlimited (must have proof of service)‎

Commencement of membership

Payment option

First Payment Date
If payment commences after start date a pro-rata invoice will be sent upon sign up

Bank Account Name

Account Number

Administration Fee (once only) up to: $5.50
Bank Account Transaction Fee: $1.20
Failed Payment Fee: $21.90

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Personal Information

Are you currently carrying any injuries, or have any medical issues that we need to be made aware of?

Yes‎ No‎

If yes, please specify below:

Have you ever had a heart attack or stroke?

Yes‎ No‎

Do you have high blood pressure?

Yes‎ No‎

Do you suffer from asthma?

Yes‎ No‎

Have you ever suffered any dizzy spells during exercise?

Yes‎ No‎

Are you currently exercising?

Yes‎ No‎

Are there any movements you cannot complete due to injury?

Yes‎ No‎

If yes, please specify below:

Please note any further information we should know about you.

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Waiver

I have volunteered to participate in a fitness program / personal training provided to me by NBR Functional Training, which may include, but may not be limited to, strength training, mobility & flexibility training and cardiovascular exercise. In consideration of NBR Functional Training agreement to instruct and train me, I do here now and forever release & discharge and hereby hold harmless NBR Functional Training and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from.

THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT BELONGING TO TRAINER OR TO MYSELF THAT MAY MALFUNCTION OR BREAK; (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT; (3) AND/OR NEGLIGENT INSTRUCTION OR SUPERVISION

I hereby grant NBR Functional Training permission to use my likeness in a photograph, video, or other digital media in any and all of its publications, including web-based publications.

I have been informed of, understand and am aware that any exercise program, whether or not requiring the use of exercise equipment, is a potentially hazardous activity. I also have been informed of, understand and am aware that any exercise and/or fitness activities involve a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death, and that I am voluntarily participating in these activities and using equipment with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity, or death.

I have been advised that an examination by a medical doctor should be obtained by anyone prior to commencing a new fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed if there are any health / medical concerns. If I have chosen not to obtain a medical doctor’s consent prior to beginning this fitness assessment / program with NBR Functional Training, I hereby agree that I am doing so solely at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all fitness related activities and/or exercises in which I participate.

I hereby assume full responsibility for any and all risks that I am exposing my child or minor (under age 18) to as a result of bringing my child or children to NBR Functional Training facility and its programs/classes. I further accept full responsibility for any type of harm, injury or potential for death that may result from my child’s participation in any play activity, Kids Functional Training Classes / Teens Kickboxing or general presence in the gym environment. NBR Functional Training informed me that there is no supervision of children, other than that of the parent or legal guardian who is responsible for their own child and I fully understand the same. The gated kids area and upstairs seated area is an unsupervised area that may contain toys or contain items that other children have brought along with them, if there is any risk related to these objects being around or in contact with my child I willingly take that risk. I agree without reservation that I must explain to my child the rules of the gym and that no children are allowed to play on the equipment at any time without express gym owner permission and adult supervision. Should permission be given I further accept any risk to my child or children.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST NBR FUNCTIONAL TRAINING FOR THEIR NEGLIGENCE OR THAT OF THEIR EMPLOYEES, AGENTS, OR CONTRACTORS.

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Terms & Conditions

Memberships are required to be paid in advance via Direct Debit payments or monthly bank transfers 7 days notice in writing to change or hold membership, (holding fee applies) 30 days notice in writing to cancel membership In signing this form you are agreeing to the above terms and conditions for all memberships.

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