17 Years and Under - Membership Paperwork

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17 & UNDER MEMBERSHIP FORMS
World Gym Burpengary | 159-161 Station Road, Burpengary Q 4505 | P 3053 3170
17 & Under's Name*
Are you part of a school based program?*
- Yes
- No
Are you interested in potentially joining the gym after your program?*
- Yes
- No
What is the name of your School?*
Date of Birth*
Day
Month
Year
Gender*
- Male
- Female
Contact Mobile Number*
Email*
Address*
Street Address
Have you been referred to by a GP or Specialist?
- Yes
- No
Please provide Doctor's Name and Contact Number:
Emergency Contact Name*
Emergency Contact Phone Number*
Relationship to 17 & Under Member*
Please note – in case of emergency, an ambulance may be used to transport your child to the nearest hospital or medical center.
17 & Under Member to Consent*
I agree to the following:

THIS IS A LEGALLY BINDING WAIVER, RELEASE AND INDEMNIFICATION AGREEMENT
PLEASE READ THIS AGREEMENT CAREFULLY BEFORE SIGNING
WE RECOMMEND THAT YOU & YOUR PARENTS OR LEGAL GUARDIANS OBTAIN MEDICAL/LEGAL ADVICES BEFORE SIGNING

Burpengary Gym Pty Ltd ABN 18 614 531 467 trading as World Gym Burpengary location is a licence of World Gym International Inc and is independently owned and operated.
For the purpose of this Agreement, World Gym includes Burpengary Gym Pty Ltd ABN 18 614 531 467, World Gym International Inc, and collectively their owners, directors, other office holders, shareholders, employees, agents, independent contractors and sub-contractors, affiliates, successors and assigns (hereinafter collectively “World Gym”).

In consideration of my use of World Gym cardiovascular equipment, weight machines, apparatus and/or all other equipment and facilities within the World Gym premises (hereinafter collectively “the Equipment”), I hereby stipulate, realise, accept and agree to all the risks of cardiovascular exercise, weight lifting, weight training and/or body building, boxing, and all other forms of classes and exercises, whether active, passive or otherwise (collectively “the Exercises”). I am fully aware of the possibility of mechanical and/or other malfunctions of the Equipment whether or not due to the negligence of World Gym or otherwise, as well as the possibility of injury to me as a result of my or others’ use of such Equipment and/or engaging in the Exercises.

I fully understand and accept the serious consequences which might result due to my involvement in using the Equipment and/or engaging in the Exercises while at the World Gym premises. Based on that understanding, I voluntarily assume any and all risk of, and hereby fully, unconditionally and forever release World Gym from any loss, damage, injury or claims of any kind whatsoever, including death, that relates to my or others’ use of the Equipment and/or engaging in the Exercises.

I represent and warrant that I am in physically sound condition and I have no disability or impairment that would prevent me from engaging in the Exercises that would be detrimental to my health, safety or physical condition. I am in good health and have no physical conditions that would be aggravated by my involvement in using the Equipment and/or engaging in the Exercises nor do I have any physical limitations that would procure such involvement.

I have medical approval to proceed with using the Equipment and engaging in the Exercises and these shall be undertaken by me at my sole risk. I understand and agree that World Gym is NOT responsible for evaluating my physical condition and will not undertake to do so.

I understand that World Gym will not provide or pay for medical and/or hospitalisation care or insurance for my benefit in the event of any injury to me occurring as a result of my being at the premises of World Gym, using the Equipment and/or engaging in the Exercises.

I will abide by the World Gym Rules and Regulations, which may be changed/updated from time to time at World Gym’s absolute sole discretion. I will cause my guests to comply with all Rules and Regulations at all times. World Gym shall have the right, in its sole and absolute discretion at all times, to cancel my membership, and in such event I will not be entitled to a refund for any prepaid membership fees that would have been accrued for the rest of the term.
In attending World Gym and using its Equipment and/or engaging in the Exercises, I agree that I am doing so at my own risk.

I understand that it is not World Gym’s responsibility to supervise my or others’ use of the Equipment or conduct within or around the premises, and I understand and agree that World Gym shall not be liable or responsible for any personal injuries (including death) or property loss, theft or damage I sustain on or around the premises of World Gym, whether or not World Gym is alleged to be negligent.

I hereby assume all responsibility for any personal injuries (including death), property loss, or property damage that I may suffer, or that I or any of my guests cause others to suffer, in connection with my, or my guests’, use of the Equipment or my presence within or around the premises of World Gym. With Full knowledge of the consequences, I am waiving my right to sue, and I voluntarily and expressly waive and agree to unconditionally, fully and forever release World Gym from all liability or claims for, or relating to, any personal injury (including death), property loss, theft or property damage, tortious acts or omissions, unlawful acts or omissions, or other claims of whatever nature sustained or asserted by me in connection with my, or others’ use of World Gym using the Equipment and/or engaging in the Exercises or my or others’ presence or conduct on or around the premises of World Gym, and notwithstanding the negligence or alleged negligence of World Gym.

I also assume full responsibility for, and agree to indemnify, defend and hold harmless World Gym, against any claims, damages, liability or expenses (including all legal fees) for, any personal injury (including death), property loss, theft or damage, tortious acts or omissions, or other claims of whatever nature asserted by any other person or entity against World Gym in connection with my, or my guests’, use of the World Gym Equipment and/or engaging in the Exercises or my, or my guests’, presence or conduct on or around the premises of World Gym, and notwithstanding the negligence or alleged negligence of World Gym.

I UNDERSTAND THAT THESE PROVISIONS CONTAIN A COMPLETE AND UNCONDITIONAL WAIVER AND DISCLAIMER IN FAVOUR OF World Gym. I understand that by signing below, I am waiving my right to sue World Gym if I suffer any injury, losses or damages of any nature whatsoever or even death. I also understand that, by signing below, I am agreeing to indemnify World Gym and I am taking full responsibility for any claims or damages that may be made against World Gym by any other person as the result of my, or my guests’, acts or omissions within or around the premises of World Gym.

This waiver, release and indemnification will survive the termination of my membership and shall be effective not only from the date hereof, but also on all occasions subsequent hereto.

I acknowledge that, at times, World Gym may be unsupervised and I accept full responsibility for my own actions during these times.

MEDICAL/LEGAL CAPACITY
I have been advised to obtain medical and legal advice before joining World Gym, using the Equipment and performing the Exercises. I confirm I have the sound mind and legal capacity to sign this Agreement, and I am fully aware of the risks involved.

SUCCESSORS
This Agreement binds my successors and estate.
Consent*
Aged 17 and Under has agreed to the following:
I understand:-
* I can participant in all Group Fitness Classes including World Gym Athletic Classes.
* I can attend Personal Training sessions.
* I am eligible to participate unsupervised resistance training on provision that- a) qualified staff member has assessed the pre-screening form referring to an Allied Healthcare Professional if required.
* I have access to: use cardiovascular equipment, pin loaded machines & free weights.
With regard to the boxing Ring ;
a) Protective equipment such as mouthgaurds, 16 oz gloves, and headgear MUST be worn, and an authorised boxing coach must be present for sparring sessions.
b) Absolutely NO work shoes to be worn inside the Boxing Ring.
c) No use of boxing ring while scheduled classes are on.
d) Please wipe down floor after use.
e) No use of boxing ring outside of staffed hours which are ;
Mon- Thurs - 5 am - 8 pm
Friday - 5 am - 6.30 pm
Saturday - 7 am - 4 pm
Sunday - 8 am - 4 pm
f) No horseplay or misusing boxing ring or boxing equipment.

* 17-years must be accompanied by Parent/Guardian: when using the Relaxation Zone.

* 17 year–old is prohibited from purchasing, sampling or being supplied with supplements and energy drinks (that is not met by supplier recommendation) within the gym.
Guarantor
First and Last Name of Guarantor
Contact Number (Guarantor)
Email (Guarantor)
Relationship to the member by the Guarantor:
Guarantors Address
- Same as Under 17
- Different from Under 17
Guarantor Address
Street Address
Consent
AS THE GUARANTOR - I AGREE AND UNDERSTAND THE FOLLOWING:
If membership fees are not met I understand (the Guarantor) that I may be held personally liable for any Debt Owing by the member (named above) and take the place of the member (name above) under the terms of the contract the member has entered into.

I have read and understood my obligations as Guarantor.
Guarantor's Signature
PRE-SCREENING QUESTIONS
This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by World Gym, Exercise and Sports Science Australia, Fitness Australia or Sports Medicine Australia for any loss damage or injury that may arise from any person acting on any statement or information contained in this tool This tool is used identify those individuals with a known disease, or signs or symptoms of disease, who may be at a higher risk of an adverse event during physical activity/exercise. This stage is self administered and self evaluated
HEART - LUNG - OTHER SYSTEM
Has your child suffered from or have a HEART CONDITION?*
- Yes
- No
Please provide details:
Does your child have CYSTIC FIBROSIS?*
- Yes
- No
Please provide detail:
Does your child have DIABETES TYPE 1 OR TYPE 2?*
- Yes
- No
Please provide details:*
Does your child suffer from HIGH BLOOD PRESSURE?*
- Yes
- No
Please provide details:*
Does your child have HIGH CHOLESTEROL?*
- Yes
- No
Please provide details:*
Does your child suffer from ASTHMA?*
- Yes
- No
Please provide details:*
Does your child suffer from ANAPHYLAXIS?*
- Yes
- No
Please provide details:
OTHER*
- Yes
- No
Please provide details:*
SIGNS AND SYMPTOMS
Does your child experience, or has your child ever had:
1. Epilepsy, seizures or convulsions? If yes, is it at rest or during exercise?*
- Yes
- No
Please provide details:*
2. Fainting – if yes, please specify*
- Yes
- No
Please provide details:*
3. Dizzy spells – if yes, please specify*
- Yes
- No
Please provide details:*
4. Heat stroke/heart related illness – if yes, please specify if yes, please specify*
- Yes
- No
Please provide details:*
5. Increased bleeding tendencies/haemophilia? – if yes, please specify*
- Yes
- No
Please provide details:*
OTHER:*
- Yes
- No
Please provide details:*
7. Does your child have or had an eating disorder? – if yes, please specify.*
- Yes
- No
Please provide details:*
8. Does your child take medication? If yes, please specify.*
- Yes
- No
Please provide details:*
If your child is taking medication, please state any side effects experienced, as a result of taking this medication.
BONE/MUSCLE SYSTEM
In the last 6 months, has your child experienced any muscle pain during exercise?*
- Yes
- No
Please provide details:*
Please detail if a Doctor has treated this pain?
Has your child broken any bones or suffered any serious injuries in the last 12 months?*
- Yes
- No
Please provide details:*
BRAIN/ MUSCLE SYSTEM
Does your child have, or has your child had difficulty/problems with any of the following:
- Vision
- Hearing
- Speech/Language
- Motor sensory skills
- Sleep apnoea
Please provide details:*
Has your child ever experienced a brain or spinal injury? Please specify.*
- Yes
- No
Please provide details:*
SPECIAL CONDITIONS
Does your child:
- use a puffer or ventilator for asthma?
- self-administer for diabetes?
- have a chronic disability or chronic illness?
- allergic to food, medication, pllens or any other allergens or specific environments?
- follow a special diet?
- been diagnosed with a nutritional deficiency?
Please provide details:*
GENERAL HEALTH
Does your child:
- Has your child had any surgery in the last 12 months?
- Are you aware of any medical condition/reason that may affect your childs ability to exercise in a program?
- Other
Please provide details:*
I believe that to the best of my knowledge, all information I have supplied for my child within this tool is correct. If any information is to change regarding the above child I shall make a member of staff aware.
I/We UNDERSTAND THAT THESE PROVISIONS CONTAIN A COMPLETE AND UNCONDITIONAL WAIVER AND DISCLAIMER IN FAVOUR OF World Gym. I/We the undersigned being the Child’s parents or legal guardians or guarantors acknowledge reading the terms of this Agreement, and accept the terms and conditions herein. I/We understand that by signing below, I/We am/are waiving my/our right to sue World Gym if the Child suffers any injury, losses or damages of any nature whatsoever or even death. I/We also understand that, by signing below, I/We am/are agreeing to indemnify World Gym and I/We am/are taking full responsibility for any claims or damages that may be made against World Gym in respect to the Child’s use of the Equipment and/or engaging in the Exercises and/or simply being present at World Gym.*
PARENTS OR LEGAL GUARDIANS OR GUARANTORS CONSENT
I/We UNDERSTAND THAT THESE PROVISIONS CONTAIN A COMPLETE AND UNCONDITIONAL WAIVER AND DISCLAIMER IN FAVOUR OF World Gym. I/We the undersigned being the Child’s parents or legal guardians or guarantors acknowledge reading the terms of this Agreement, and accept the terms and conditions herein. I/We understand that by signing below, I/We am/are waiving my/our right to sue World Gym if the Child suffers any injury, losses or damages of any nature whatsoever or even death. I/We also understand that, by signing below, I/We am/are agreeing to indemnify World Gym and I/We am/are taking full responsibility for any claims or damages that may be made against World Gym in respect to the Child’s use of the Equipment and/or engaging in the Exercises and/or simply being present at World Gym.
CONSENT
I hereby acknowledge that by signing: • The information provided above about my child’s health is to the best of my knowledge correct. • I will inform you immediately if there are any changes to the information provided above. • I give permission for my child to commence your training program.
Parent/Guardian's Signature*
Member's Name (17 & Under)*
17 & Under's Signature
MC Consultant*

17 & UNDER MEMBERSHIP FORMS

Guarantor

PRE-SCREENING QUESTIONS

HEART - LUNG - OTHER SYSTEM

SIGNS AND SYMPTOMS

BONE/MUSCLE SYSTEM

BRAIN/ MUSCLE SYSTEM

SPECIAL CONDITIONS

GENERAL HEALTH

CONSENT