> **2008 08 Card Number \_\_\_\_\_\_\_\_**

# **Wallops Fitness Club**

**'08 Membership Application**

**Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**(Please Print)**

**Employer: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Work Phone \# \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Mail Stop \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Email Address
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**(Building)**

**Membership in the Wallops Fitness Club is open to employees of all
organizations covered by the Wallops Morale Activities Committee bylaws,
pay their annual dues and abide by the Club rules.**

**Membership is for the calendar year beginning January 1, 2008.**

**Please read and sign the following:**

**In consideration of being accepted as a member of the Wallops Fitness
Club, I hereby certify that I am in good health and have received
permission from my physician to participate in vigorous physical
activities. I understand that the use of Wallops Fitness Club equipment
and facilities could result in injury to myself or others. I hereby
affirm that I will not use the Club's equipment or facilities without
knowing and following safe and proper techniques and procedures. I
forswear for myself, my heirs and executors, any and all claims against
the Wallops Fitness Club, the Morale Activities Committee, the National
Aeronautics and Space Administration and any representatives thereof,
for any injury I may suffer as a result of using Wallops Fitness Club
equipment or facilities or participating in any activity sponsored by
the Wallops Fitness Club even if it can be shown that the injury was the
result of negligence or improper maintenance. I also agree that as a
member of the Wallops Fitness Club, I share in the responsibility in
maintaining the Club equipment in safe working condition and the
facilities in a neat and orderly fashion.**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Signature Date**

**Last Year's Card Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Locker Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

** Please add my name to the waiting list for a locker**

**Please Turn Over And Complete**

**Physical Activity Readiness Questionnaire (PAR-Q)**

The PAR-Q is designed to help you help yourself. Many health benefits
are associated with regular exercise, and the completion of the PAR-Q is
a sensible first step to take if you are planning to increase the amount
of physical activity in your life.

For most people, physical activity should not pose any problems or
hazard. The PAR-Q has been designed to identify the small number of
adults for whom physical activity might be inappropriate of those who
should have medical advice concerning the type of activity most suitable
for them.

Common sense is your best guide in answering these few questions. Please
read them carefully and check the correct answer opposite the question
as it applies to you.

  ------ ------ ---------------------------------------------------------
  YES    NO     

                1\. Has your doctor ever said that you have a heart
                condition and that you should only do physical activity
                recommended by a doctor?

                2\. Do you feel pain in your chest when you do physical
                activity?

                3\. In the past month, have you had chest pain when you
                were not doing physical activity?

                4\. Do you lose your balance because of dizziness or do
                you ever lose consciousness?

                5\. Do you have bone or joint problems that could be made
                worse by a change in physical activity?

                6\. Is your doctor currently prescribing drugs (for
                example, water pills) for your blood pressure or heart
                condition?

                7\. Do you know of [any other reason]{.underline} why you
                should not do physical activity?
  ------ ------ ---------------------------------------------------------

If you answer "YES" to one or more questions, you must get medical
clearance from your personal physician before you can use the facilities
of the Wallops Fitness Club.

**In case of emergency do the following: 1) assess the problem; 2)
proceed with "common sense"; 3) if necessary call ext. 911 (for fire,
sickness or injury) or call the "Help Desk" at ext. 2466 (for building
problems such as water leaks, broken windows, etc.); 4) state the
problem; 5) follow their instructions; 6) and / or use your common sense
to safeguard yourself and others from harm.**

I, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ herby certify that I have read and
understand all of the above information and have answered all questions
truthfully. It my responsibility to notify the Fitness Club of any
changes in thy health condition that might affect my ability to safely
participate in physical activity.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Sign and date here).