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Welcome to 99 Family! Please read and sign the waivers below to complete your membership sign-up.

Membership Agreement & Payment Terms

I apply for membership at the 99 BARBELL LLC at 36 W LIVE OAK AVE, ARCADIA, United States, CA, 91007, on December 26, 2024 I represent and warrant that I am 18 years of age or older and all facts and information set forth in this agreements are true, correct and complete.

In consideration of being allowed to participate and access 99 Barbell LLC, hereafter referred to as “the gym”, I undersigned, acknowledge, appreciate, and agree that:

A. Membership Options:

All memberships are either Month-to-Month or Pre-Paid Annually

  • Month-to-Month Memberships: $59.99 monthly

All Month-to-Month memberships are required to pay for their First and Last month of membership dues plus the initiation fee at Sign-Up.

  • Annual Payments $660 annually

Annual Payments memberships are required to pay for the full year in advance. Payment is due at Sign-Up

  • Premium Training Membership

Premium Training Membership is non-refundable and paid monthly.

  • Short-term passes $45/ 1 week pass, $75/ one month pass

Short-term passes are either 1 week or a month pass. Payment is due at sign-up.​

B. Payment Terms:

All payments for memberships and guest fees are collected via auto-debit (i.e., electronic funds transfer) from either an ACH (Automated Clearing House, electronic fund transfer) or debit card. By providing your checking account or debit card information you allow the gym to automatically withdraw dues and fees as they come due each month. If I change financial institutions, I will provide the gym in writing or in person all the information needed to update my billing.

  1. Month-to-Month Payments: Under this option, members must pay the First and Last fees plus the initiation fee today upon signing this contract. All fees paid are non-refundable.
  2. Annual Payments: Under this option, members must pay for the full term year at sign-up. Payments are non-refundable and non-cancellable after 2 business days of signing this agreement.
  3. Premium Membership: Under this option, members must pay in full and all fees paid are not non-refundable or transferable. 
  4. Short-Term Passes: Under this option, members must pay in full and all fees paid are not non-refundable or transferable.

C. Cancellations:

Members have the right to rescind Annual contracts membership only within two (2) business days after signing this Contract. Upon such rescission, the member will receive a full refund of all monies paid, including initiation fees. All cancellations must be received either in person or in writing and e-mailed to 99barbell@gmail.com.

All month-to-month membership is non-refundable once purchased

  1. Month-to-Month memberships: Under this option, members can cancel their membership no later than fifteen (15) day before their billing date. For example, if the member’s billing date is on June 15th, the member must notify the gym to cancel their membership no later than June 1st for the cancellation to be effective. Cancellation received after the 1st will not take effect until the following month or in this case July. Please ask our front desk if you have questions regarding this term. The gym does not offer refunds or partial refunds for membership fees paid, and the gym will not prorate a canceled membership. All month-to-month fees paid are non-refundable.
  2. Annual Contract Memberships: Under this option, members have two (2) days after signing this agreement to rescind their annual paid membership. If members cancel their membership within the three (3) days' rights of rescission, the gym will refund all monies paid including initiation fees.
  3. Premium Membership: Under this option, members can cancel their membership anytime before the billing date. For example, if the member's billing date is June 15th, the member must notify the gym to not renew their membership any time before June 15th. If a request to not renew is received after June 15th, the request will not take into effect until the following billing cycle. Please ask our front desk if you have more questions regarding these terms.  The gym does not offer refunds or partial refunds for membership fees paid, and the gym will not prorate a canceled membership. All premium fees paid are non-refundable. Members are able to downgrade to the general membership by paying the first and last of the general membership fee. At any given time members are also able to switch back to premium membership. Please notify our front desk for more details.
  4. Short-Term Passes: Under this option, all fees paid are non-fundable and non-transferable.

D. Other Fees & Dues:

  1. Late Payment & Declined Credit Card Fees: A $15 late payment will be due and payable for payments received 5 days after the billing date. Membership fees must be paid on or before the billing date. Members who are not current will not be granted access to the facility.
  2. Right to Modify Dues: Members with Month-to-month Membership may have their dues increased at any time. We will inform members of increased dues at least 30 days before the billing date.

E. Freeze Policy for Memberships

   Members in good standing with all fees paid and are current on monthly or prepaid dues are eligible to freeze their accounts. A notice for freeze must be given to the gym in person or via e-mail to 99barbell@gmail.com at any given time.

  1. Month-to-Month Memberships: Under this option, members may put their membership on hold, in one calendar month increment for a fee of five ($5) per month on freeze.
  2. Annual Contract Membership: Under this option, members may put their membership on hold for up to 3 months max and your commitment period and obligation will be extended for the amount of time your membership was on freeze. No further dues will be collected during members' approved freeze and their rights to access the gym during the freeze will be suspended
  3. Premium Memberships: Under this option, members are not eligible to freeze accounts. Training sessions must be used within 45 days of the initial billing date.
  4. Short-Term Passes: Under this option, members are not able to freeze accounts. Short-term passes will expire once the paid days are up.

I Agree

Facility Rules and Regulation

A. Facility Hours & Access

Members will have access to the facility during operating hours.

Gym Operating hours:

(Gym access is granted via automatic Door Access)

Monday - Friday: 5:00am – 9:00pm

Saturday/Sunday: 6:00am – 5:30pm


Non-Staffed Hours: 

(Non-Staffed hour with entry granted via automatic Door Access)

Monday – Friday: 5:30am - 9:30am

Saturday – Sunday: 6:00am - 5:30pm

Hours May Change Without Notice

 

Gym Office Hours:

(Staffed hours)

Monday - Friday: 9:30am - 9:00pm

Saturday / Sunday: 10:00am – 5:30pm

Hours May Change Without Notice

99 Barbell LLC reserves the right to change operating hours at its sole discretion without any effect to this agreement.

 

B. Facility Access

Members will be granted access via Automatic Door Access Monday through Friday from 5:00am to 9:00pm and Saturday and Sunday 6:00am to 5:30pm.

Please refer to the Door Access Waiver below for full details. Member must read and sign the Door Access Waiver to be granted entry during Unstaffed Hours.

  • 99 Barbell Member must use I.D. Key Tag for admittance into the facility.
  • ID. Key Tag may not be shared and anyone found sharing will have their membership revoked.
  • A $3 fee will be charged to replace a lost or damaged I.D. Key Tag.


C. Limited Availability

   99 Barbell LLC may close its Facility for seminars, certifications, maintenance, selected holidays, and other hours based on municipal requirements. 99 Barbell LLC may delete, change, discontinue, repair, or replace any part or all of the Facility without any effect on this Agreement. 99 Barbell LLC will not be responsible for refunding any membership fees paid, including advance payments up to 12 months. All membership fees paid are non-refundable, non-transferable, and noncancellable.

D. Limited Use

  If you know or should know you have a problem that might prevent you from using the gym (i.e., medical or family emergency, business travel, vacation, etc…) and you sign this Agreement, you agree that your membership is limited accordingly. However, because this is your choice, you must still pay your monthly dues as if you could use the Facility; there will be no carry-over of monthly dues into subsequent months for any time unspent using the Facility in a previous month. See our Freeze Policy for Term Memberships and our Cancellation Policy for other options.

E. Rules and/or Regulations

  Members who do not observe the gym rules and regulations or who abuse equipment in any fashion will be asked to leave. The management reserves the right to terminate the membership of anyone who refuses to follow any of 99 Barbell LLC rules or regulations. Not all rules and regulations are listed in this agreement. The gym reserves the right to add, change or remove rules, conditions of membership, opening and closing hours, and all services and facilities offered by the gym.

99 Barbell Gym Rules & Regulation

To keep our facility clean and accessible for everyone, please make sure to read our rules.

  • Respect the facility and pick up after yourself.
  • We offer different types of weight plates: Calibrated Plates, Bumper Plates, and Cast Iron Plates. Please do not mix the plates. Bumper with bumper, calibrated with calibrated and cast iron with cast iron.
  • We have a variety of high-quality expensive barbells and in order to maintain the longevity of our equipment, we ask for members to follow our rules regarding our barbells and their usage. Each barbell is labeled and marked.
  • Power Bars: Use for Squat, Deadlift, and Bench
  • Deadlift Bars: Strictly Deadlift ONLY
  • Squat Bars (55lb): Squat, Bench, Deadlift

Please do not use any of the barbells listed above for weight lifting, rack pulls, t-bar rows, or any other lifts that are not listed above

  • Black Olympic Barbell with 99 Barbell Caps may be used for everything. 

All other specialty bars have their specific usage and purpose. Please ask our staff if you are unsure of how to use the bars.

  • We have added straps to our Power Racks to prevent bars from bending when barbells are dropped due to missed lifts or mishaps. If barbells are bent due to the negligence of the member, the member will be required to pay for the bar. You bend, you pay.
  • Please lift safely and always ask for someone to spot if needed.
  • Cardiovascular equipment use is limited to 20 minutes during peak hours.
  • Please do not use weights on the cardiovascular machines.
  • Members are required to be fully clothed and have closed-toe shoes at all times. If members choose to be barefoot, we are not responsible for any injuries that may occur due to the members’ negligence.
  • Members are not allowed to be topless inside the gym. This is for hygienic purposes and to keep our facility clean.

F. Lost Articles

   99 Barbell LLC assumes no responsibility for lost or stolen articles. Lost and found articles not claimed after 30 days will be donated to charity or thrown away.

G. Prohibited Activities

   Alcohol, drugs (including steroids), and smoking are prohibited within the Facility. Member agrees to not use the Facility or engage in any activity at 99 Barbell LLC while under the influence of drugs, alcohol, or medication that may impair the member.

H. Conduct

   99 Barbell LLC is committed to the health, safety, and welfare of each of its members and staff and will not tolerate unreasonable, threatening, obscene, harassing, indecent, or illegal behavior. The gym has the right to judge behavior and respond accordingly. This right includes, but is not limited to, termination of membership without refund of any member engaging in unacceptable behaviors.

I. Damages

Members shall pay for any damages to 99 Barbell LLC property or equipment(s) which result from the willful or negligent conduct of a member or member’s guest. Please report any injury, or broken or damaged equipment immediately to staff on duty.

  • If at any given time you are unsure of how to operate the equipment inside the facility, please don’t hesitate to ask one of our staff members during staffed hours. They will be more than happy to assist you

I Agree

Door Access Waiver

Participant release of liability and assumption risk agreement. Please read before signing. In consideration of being allowed to participate and granted door access at 99 Barbell LLC, hereafter referred to as “the gym”, I undersigned, acknowledge, appreciate, and agree that:

  1. Door access is only available to active 99 members only. If I fail to make payments on my membership, my door access privileges will be suspended until my account is reconciled.
  2. I agree that improper authorized use of the facility may result in member suspension or cancellation. I agree to not let anyone use my key tag for any reason, and I agree to report any situation that appears to be card sharing to the gym staff. A security “Tailgate” system has been installed to monitor and record instances of “tailgating”. I understand that one act of card sharing will result in immediate membership suspension or termination. A $50 penalty fee will also be charged to my account. Additionally, I recognize this is a violation, and personally take on any and all legal liability should injury occur, to your unauthorized guest(s). The gym reserves the right to suspend or cancel the rights, privileges, and membership of any members whose actions are detrimental to the use, safety, and enjoyment of the facility.
  3. I understand that if I’m planning on bringing in a guest to the gym during Door Access Hours it is my obligation to contact the gym a day in advance during office (staffed) hours. If I’m unable to contact the gym during office (staffed) hours, it is my responsibility to notify the gym via email or text that I will be bringing a guest and attach the guest’s driver's license and payment method. The $15 Drop-In FEE (reduced exclusive rate for 99 members) can either be paid via Venmo (Barbell99) or charged directly to their account.

I understand and am aware that there will be no supervision or assistance during the Non-Staffed Hours. (Monday through Friday from 6 am to 9:30 am and Saturday and Sunday from 6 am to 10:00 am. All hours (Non-staffed, Office and Gym) hours are subject to change at the sole discretion of the gym. I am aware that if I get injured, become unconscious, suffer a stroke or heart attack, or any other medical emergency or event that there will likely be no one to respond to my emergency, and the gym has no duty to provide assistance to me while I’m at the gym during Non-staffed Hours. I understand that even though the gym is fully equipped with surveillance cameras, these records, are not monitored continuously; help will not be available during Non-Staffed Hours. However, a first aid kit and emergency alarms are located in the facility that, when activated, will alert emergency services. In addition, alert pendants will be available that, when activated will connect to 911.

I voluntarily assume the risk of injury, accidents, death, loss, or cost of damage to my person or property which might arise from my use of the gym, and I agree to hold harmless and release the gym and all affiliated corporations, and its officers, directors, board members, agents, employees, representatives, executors, and all others from any and all liability. I, for myself, my heirs, personal representatives, or assigns, do hereby release, waive, discharge, and covenant not to sue all of those mentioned and any others acting on their behalf from any responsibility or liability for any personal injury, accident or illnesses (including death) to myself, and property loss arising from my participation in any activities or the use of any equipment at the gym during non-staffed hours. I agree that I will look over the documents which will be sent to the email I used to sign-up once I have completed my membership sign-up. The document will include the location of the emergency alert system and how to use the door access equipment.

I certify that I have read and understood all the terms of the gym agreement and agree to continue to abide by all of the terms of this agreement.

PLEASE UNDERSTAND THAT THE GYM HAS A STRICT POLICY TO PROTECT OUR MEMBERS AND OUR BUSINESS LIABILITY. MEMBERS WHO HAVE NOT SIGNED THIS WAIVER WILL NOT BE GRANTED DOOR ACCESS.

I Agree

Photography/Video/Name Release

Participants involved in any activities offered by 99 BARBELL FITNESS may be photographed or videotaped during training. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the 99 BARBELL LLC website or in any editorial, promotional or advertising material produced and/or published by 99 BARBELL LLC. The undersigned hereby grants 99 BARBELL LLC the right to use their name. The undersigned waives the rights to inspect or approve such materials created and/or used by or on behalf of 99 BARBELL LLC pursuant to this release. Participants release 99 BARBELL LLC, its officers, employees, agents, assigns, successors, and licensees from any claims that may arise therefrom, including but not limited to any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity or copyright.

Waiver and Release of Liability

 Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of physical training. These risks include but are not limited to: falls which can result in serious injury or death; injury or death due to negligence on the part of myself, my training partner, or other people around me; injury or death due to improper use or failure of equipment; strains and sprains. I am aware that any of these above-mentioned risks may result in serious injury or death to myself and or my partner(s).

 I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity or class while at, or under the direction of 99 Barbell LLC. I acknowledge that I have no physical impairments, injuries, or illnesses that will endanger me or others. I acknowledge that there may be an animal(s) present in the facility and I waive all rights to all claims for liability and cause(s) or actions that may arise due to the animals in the gym, including allergies, aggressive pet(s) and or any other incidents that may occur due to the presence of the animals in the facility.

Release

In consideration of the above-mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities offered by 99 Barbell LLC, I, for myself, my heirs, successors, personal representatives or assigns, hereby release, waive, discharge, and covenant not to sue 99 Barbell LLC, its directors, officers, employees, volunteers and agents from any and all liability, from any claims including the negligence of resulting in personal injury, accidents, or illnesses (including death), and property loss arising from actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, classes, observation, and use of facilities, premises, or equipment. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect. If I am signing on behalf of a minor child, I also give full permission for any person connected with 99 Barbell LLC to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and/or surgical care for myself and or the child and to transport myself and or the child to a medical facility deemed necessary for the well-being of myself and or the child.

 

Indemnification

The participant recognizes that there is risk involved in the types of activities offered by 99 BARBELL LLC. Therefore the participant accepts financial responsibility for any injury that the participant may cause either to him/herself or to any other participant due to his/her negligence. Should the above-mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless 99 BARBELL FITNESS, their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by 99 BARBELL FITNESS, at the main building or abroad. This includes but is not limited to parks, recreational areas, playgrounds, areas adjacent to the main building, and/or any area selected for training by 99 BARBELL LLC.

Signature

I have read and understood the foregoing assumption of risk and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.

December 26, 2024


First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Please Upload Your Driver's License
  
Upload Driver's License *
Valid file types: JPG, GIF, PNG, and PDF
Electronic Funds Transfer (EFT) Authorization Application

I authorize the financial institution named below to accept Direct Payment instructions and to debit my account indicated below or credit my account if it is necessary to make corrections. Inputting your credit card below does not finalize the purchase of your gym membership. The below information is collected to authorize 99 Barbell LLC to charge the account each month. Please complete your registration through Rhinofit website which will appear after you've completed the waivers.




Full Name *

99 Barbell General Monthly Membership: $60

First + Last Fee Due at Sign up $120

**THIS IS NOT PAYMENT FOR MEMBERSHIP. PLEASE COMPLETE REGISTRATION THROUGH RHINOFIT WEBSITE***



Credit Card Number: (VISA, MASTERCARD, AND DISCOVER ONLY. **NO AMEX**) *

Credit Card Exp. Date *

Membership Start Date *

I hereby authorize 99 Barbell LLC, hereinafter called Company, to initiate debit entries to my bank account. This authorization is to remain in full force until Company has received written notification from me of its termination in such time and in such manner as to afford Company a reasonable opportunity to act on it (30 days). I understand that this payment plan may be canceled by Company at any time. I represent and warrant that I am authorized to execute this Authorization Agreement and I indemnify and hold the Company, bank and their agents harmless from damage, loss or claim resulting from all authorized actions hereunder.


Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Health Questionnaire
Do you Smoke?*
No
Yes
Do you Drink Alcohol?*
No
Yes
Do you Take Prescription Medication?*
No
Yes
Do you Have Back, Knee, or Shoulder Pain?*
No
Yes
Do you Have any Previous Injuries or Surgeries?*
No
Yes
Do you High Blood Pressure, Asthma, Diabetes, or a Heart Condition?*
No
Yes

Do you have any Other Health Conditions?
Are you signing as a parent or guardian?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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