Last Name _________________________ First _____________________ MI _______________
City ____________________________ State ___________________ Zip Code ______________
Social Security Number _________________________ Date of Birth ______________________
Home Phone Number (____)________________ Business Phone (____)____________________
Today’s Date _________________________ Expiration Date ____________________________
Membership Type _____________________________ Member Number ___________________
Contact Person in Case of Emergency _______________________________________________
Telephone Number of Contact Person (____)__________________________________________
I, _____________________________ , hereby understand and acknowledge upon payment of the required fee that the North Allegheny School District (hereinafter “District”) hereby grants me permission to use and enjoy the Baierl Center facilities, including all cardiovascular equipment, weight lifting and exercise equipment now and hereafter available for use during the terms of this agreement.
I acknowledge that I have read, understand and agree to the rules and conditions for the use of the Baierl Center. Further that the terms and conditions of this agreement and the rules and regulations are subject to change at the sole discretion of the District, with or without notice.
I understand and agree that the Baierl Center’s days and hours of operation are within the sole discretion of the District and may be changed at any time and for any reason with or without notice.
I understand and agree that the District makes no guarantee either expressed or implied as to the type, style or number of pieces of equipment available for my use and the District retains the right to restrict the use of such equipment at any time and for any reason, with or without notice.
I understand and agree that the District, in its sole discretion, determines that I have violated the rules, policies or regulations or have engaged in any form of illegal or undesirable behavior, the District shall have the right to revoke my use of the facility. Further, in the event I should either intentionally or negligently damage any equipment or the facility in manner, I agree to reimburse the District for the cost of repair of the equipment or facility.
I understand, acknowledge and agree that all exercise and other activities shall be undertaken by me solely at my own risk and that the District, its agents, employees, board members and officials shall not be liable to me for any claims, demands, injuries, damages, suit, actions or causes of action whatsoever, including pain and suffering to my person or property, arising out of or in connection with my use of any and all the exercise facilities and services of the Baierl Center.
I understand and agree that the District has no obligation on instructing me as to the use of any equipment or exercise programs. Further, I understand and agree I am fully responsible for the operation of all equipment and for my own exercise program.
I hereby release and forever discharge the North Allegheny School District, its agents, employees, board members, and officials from any and all claims, demands, rights, and causes of action whatsoever kind and nature, arising from, and by any reason of, and bodily and personal injuries or damages to person or property which I sustain as a result of or in connection with my use of the Baierl Center facilities.
Member’s Full Signature _________________________________________________________
Signature of Parent or Guardian ____________________________________________________
(if under 18 years of age)
North Allegheny Athletic Director __________________________________________________
Total Amount of Dues _____________________ Amount Paid _____________Date ___/___/__