FitnessCenter
Membership
Application
Packet
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HealthSmartFitnessCenter
The HealthSmartFitnessCenter is designed to help each employee maximize good health, fitness, well-being and quality of life. The HealthSmart staff has a number of resources, services and programs aimed at supporting members in beginning, maintaining or enhancing positive lifestyle habits.
The HealthSmartFitnessCenter provides an opportunity for every member to improve or maintain their desired level of fitness. The fitness center is conveniently located, staffed by professionals, and designed to help you achieve your goals. The staff will work with you to set-up a specific program to meet your needs, whether you are abeginner or a advanced athlete.
Facilities
The fitness center is conveniently located in the building. It contains state-of-the-art cardiovascular and weight training equipment. There are separate areas for group exercise classes and free-weight use. Personal lockers with combination locks are available for all members in ourspacious locker room’s. We also provide towels and optional exercise clothing rental service provided for member convenience. The following is our equipment list:
Cardiovascular EquipmentCYBEXStrength TrainingCYBEXFree Weight Equipment
PRECOR Lower Body EllipticalsAB CrunchBarbells 20 – 110 lbs.
PRECOR Total Body EllipticalsArm CurlCable Crossover
CYBEX SteppersArm ExtensionDecline Bench
CYBEX Treadmills Assisted Chin Up / DipDumbbells 5 – 85 lbs.
CYBEX Upper Body ErgometerBack ExtensionFlat Bench
CYBEX Recumbent BikesDual Axis Chest PressFlat / Incline bench
CYBEX Upright BikesDual Axis Row / Rear DeltOlympic Bench
Concept II RowerDual Axis Overhead PressPreacher Curl
Schwinn Spinning CyclesHip Abduction / AdductionSmith machine
Lat PulldownUpright Bench
Lateral Raise
Leg Extension
Seated Calf Raise
Seated Leg Curl
Seated Leg Press
Hours of Operation
The HealthSmartFitnessCenter is open Monday through Friday 6:00 a.m. – 8:00 pm (except on designated HealthSmart observed holidays & summer hours on Fridays 6 am – 6 pm).
Amenities Included with your Membership
Shower facilities
Personal lockers
Steam Room
Sauna
Hair dryers
Towels (workout and bath towels)
Magazines
Additional Amenities
Optional personal exercise clothing for rent
(T-shirts, socks, shorts and mesh bag) are provided and laundered on-site.
Staff
The HealthSmartFitnessCenter is staffed by qualified health/fitness professionals who have a minimum of a bachelor's degree in health, fitness and/or exercise science. The staff is available to lead you in designing a fitness program, monitoring your progress, utilizing the exercise equipment, answering healthand fitness-related questions, leading exercise classes, and facilitating health and wellness programs.
Services Available
Group Exercise Classes: A variety of group exercise classes are offered as a part of the fitness center programming at no additional cost to members. Non-members may also participate for a fee. The group classes cover a wide variety of topics such as Spinning, aerobics, steps, muscle conditioning and flexibility.
Specialty Classes:Yoga, Pilates, Zumba and certain pre-season sport conditioning programs,like golf and tennis, are also offered at an additional cost to members and non-members.
Personal Training:Membersmay schedule personal training with the HealthSmart staff, for an additional fee.
Massage Therapy: Massage services will be available to all fitness center members through a licensed massage therapist. This service is by appointment only, at an additional cost to both members and non-members.
Membership Fees
MerbershipAnnual FeesMonth*Payment OptionsCommitment
Member / **Other$390.00$32.50EFT/CHK6 Month
*Payment OptionsEFT=Electronic Fund TransferCHK=Check
**Other = Spouses / Domestic Partners, Retirees, Contractors
New Member Enrollment Process
At the time you begin your membership, you will be required to an initialsix-month commitment period. If you desire to discontinue your membership after this commitment period, you may elect to do so by notifying the staff in writing at least two weeks prior to the day in which the membership will be terminated. If you have a medical disability verified by a physician, are relocated, or you leave the company, you may terminate your membership immediately. The New Member EnrollmentProcess is as follows:
1.Health History Questionnaire and Release of Liability and Consent: (Required- see pages 7 and 8)
A Health History Questionnaire and Release of Liability and Consent is required for all applicants. This questionnaire allows the fitness staff to identify risk factors or medical conditions, which may require specific levels or types of exercise to be restricted.
HealthSmartFitnessCenterstaff and/or your personal physician will review your Health History Questionnaire. No one else will have access to this information. It will be used only in connection with your fitness center application and/or membership. If necessary, you may be asked to obtain a signed Medical Clearance Form from your own physician prior to participating. Once your Health History Questionnaire, Release of Liability and Consent form and, if applicable, a MedicalClearance Form have been received, you will be contacted by the fitness center staff to set up appointments for the remaining steps of the new member enrollment process.
2.Pesonalized Workout:
The final step in becoming a fitness center member is a personalized workout with a staff member. At this time, you will be provided with an exercise program designed specifically for you. A staff member will provide you with instructions on how to warm-up, stretch, utilize the appropriate cardiovascular and weight training equipment, and how to properly cool-down along with how to monitor your exercise intensity. You will also bea locker with combination and you will be set-up in our computer system. Your payment form will then be processed.
3.Bio-Metric Assessment (BMA):
The optional BMA is a 30 - 45 minute screening to evaluate your current level of fitness. The bio-metric assessment will include the following:
Resting heart rate Blood pressure Body composition
Body Mass Index (BMI) Cardiovascular conditioning Muscular endurance
Flexibility
You will be eligible to undergo a re-evaluation, each year upon the annual anniversary of your BMA. You also have the option to request more frequent re-evaluations so that you can measure your progress and improvement!
4.BMAInterpretation:
Once you have completed the BMA, you will receive a confidential computerized report of your results. AHealthSmartFitnessCenter staff will review your results with you, and help you design an exercise, and/or weight management program.
Emergency
In case of any emergency within the fitness center, please either notify a staff member on duty or press the Emergency Panic Button immediately, and then follow the HealthSmartFitnessCenterposted instructions to aid in the emergency procedures.
Dress Code
Members are expected to wear modest, loose fitting clothing that is appropriate for a corporate environment (e.g., it is considered appropriate to wear shorts, T-shirts, warm-up suits, sweat suits, etc.). Socks and sneakers must also be worn at all times. The purpose of the dress code is to contribute to a comfortable, non-threatening environment and provide members with positive health and fitness experiences that can be translated into permanent life style changes.
Attendance Log-in
All members are required to log-in at the Member Check-in computer prior to exercising by typing in yourunique personalized ID. Signing in will help us to understanding the daily utilization of the fitness center.
File Updates
All members are required to update their Health History Questionnaire upon any changes in their health status wether it is positive or negative. The medical clearance form may need to be updated if there are any changes on your Health History Questionnaire requiring a medical cleanrance.
Application Instructions
- Complete the Personal Health Information & Health History Questionnaire- required (page 6 & 7).
- Sign Release of Liability and Consent form – required (see page 8)
- Fill out Electronic Fund Transfer (EFT) – required (see page 9)
- Annual Clothing Rental Agreement – optional (see page 10)
- Return / Email all documents (pages 6 – 10)
to the HealthSmartFitnessCenter.
- Call the fitness center Director at 203-605-3812if you need additional information.
Easy as 1 - 2 - 3
Anyone who would like to meet the HealthSmartFitnessCenter team and
tour the facilityis welcome to visit us.
Call us and we will take you on a tour.
203-605-3812
Personal HealthInformation
first name / last name / COMPANYDate Completed / /
activity LEVEL How many days a week do you usually get 30 minutes or more of exercise/physical activity?
None / 2 days / 4 days / 6 days1 day / 3 days / 5 days / 7 days
How intense is your activity: / Easy / Moderate / Difficult
OVERALL HEALTHHow would you rate your current level of health?
Poor / Fair / Good / ExcellentProgram / service interests In what services, programs, activities or equipment do you have an interest?
Personal Training / Walking Program / Strength Training / Cardiovascular ConditioningMassage Therapy / Group Exercise Classes / Stretching/Flexibility / Sports Conditioning
health / Welless interests Please check the topics you are interesting in learning more about:
Cholesterol/Blood Pressure / Diabetes / Weight Management / Women’s HealthTobacco Cessation / CPR/First Aid / Work Injury Prevention / Men’s Health
Back Care / Ergonomics / Stress Management / Children’s Health
Cancer Awareness / Nutrition / Self-Care / Other
Clothing rental service One time annual cost $40 All Check written out to HealthSmart Advantage
Shirt Short SocksClothing rental. XXXL XXL XL L M S XXXL XXLXL LM S L M
Once your locker and combination has been assigned, your locker number will appear on your mesh bag with your clothes inside.
LOCKER NUMBER______COMBINATION ______/ ______/ ______(Issued by Staff)
FRONT DESK MEMBER CHECK-IN (Personal ID # | | | | | | | | | max 10 characters)
E-MAIL /DISTRIBUTION LIST: Yes No E-mail:
1
Professionally managed by HealthSmartAdvantage, LLC.
Health History Questionnaire
first name / last name / COMPANYdate of birth / gender / ON-SITE OFF-SITE (Please Check Box))
work address / City / St|ZIP|
home phone / work phone / E-MAIL
primary PHYSICIAN / PHYSICIAN PHONE / PHYSICIAN fax
EMERGENCY CONTACT NAME / EMERGENCY CONTACT PHONE / RELATIONSHIP
Employment Status Full-time Contractor Intern Retiree Spouse / Domestic Partner Part-time Tenant Temporary Dependant Other
THESE QUESTIONS MAY REQUIRE A MEDICAL CLEARACE FORM. This Form provided by HSA
Female, age 55 or older ...... Yes No / Male, age 45 or older ...... Yes NoDO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING CARDIAC, METABOLIC, OR PULMONARY CONDITIONS? CHECK ALL THAT APPLY.
CARDIAC/VASCULAR / METABOLICCoronary angioplasty...... Yes No / Diabetes...... Yes No
Cardiac surgery...... Yes No / Kidney disease...... Yes No
Heart disease, heart attack, angina ...... Yes No / Thyroid or other metabolic disorders...... Yes No
Heart murmur...... Yes No / RESPIRATORY
Mitral valve prolapse...... Yes No / Asthma...... Yes No
Peripheral vascular disease...... Yes No / Chronic bronchitis...... Yes No
Stroke...... Yes No / Emphysema or chronic obstructive pulmonary disease(COPD) Yes No
Other...... Yes No / Other...... Yes No
DO YOU CURRENT HAVE ANY OF THE FOLLOWING SIGNS, SYMPTOMS, OR CONDITIONS? CHECK ALL THAT APPLY.
Ankle swelling...... Yes No / Irregular / Rapid heartbeats or palpitations...... Yes NoChest pain (at rest or exertion)...... Yes No / Shortness of breath (at mild exertion/rest)...... Yes No
Dizziness / Fainting ...... Yes No / Unexplained fatigue (unusual fatigue or shortness of breath with usual activities) Yes No
Seizure disorders / Convulsions ...... Yes No / WOMEN: Are you pregnant? ...... Yes No
If you marked “yes” to one or more of the items above, you must obtain your personal physician’s consent prior to joining or scheduling a bio-metric assessment.
DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING CORONARY RISK FACTORS? CHECK ALL THAT APPLY.
Diagnosed high blood pressure ...... Yes No / Smoking habit (within past six months)...... Yes No(or systolic BP140 or diastolic BP90mmHG on at least two separate checks) / Family history of heart disease (parents/siblings before age 55) Yes No
Hypercholesterolemia, elevated cholesterol, abnormal blood lipids
(total cholesterol200mg/dL or HDLmg/dL) ...... Yes No / Sedentary lifestyle (inactive job with no regular exercise program;
active less than 3 times per week; or no recreational pursuits) ...... Yes No
If you marked “yes” to two or more of the items above, you must obtain your personal physician’s consent prior to joining or a bio-metric assessment.
PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING CONDITIONS. THESE CONDITIONS MAY REQUIRE A MEDICAL CLEARACE FORM.
Major surgery or hospitalization within the past six months. Please explain:Anemia (severe10GM/dL) / Allergies (please explain)
Arthritis (please detail area) / Orthopedic problems (please detail area)
Chronic back problems / Other medical restrictions. Please explain:
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (PRESCRIPTION AND OVER-THE-COUNTER) .
Medication: / Reason for medication:I verify I have answered these questions truthfully and to the best of my knowledge. I will notify the staff immediately if I have any changes in my health status.
Typing my e-mail address will constitute my electronic signature and is my written authorization.
Email E-Signature: / Date:1
Professionally managed by HealthSmartAdvantage, LLC.
MyServiceAdvantage.com, LLC. – RELEASE OF LIABILITY AND CONSENT —
Fitness Management Programs and Services at FitnessCenter
(Excludes: Bio-Metric Assessments, Health Screenings, Personal Training, and Massage Therapy)
In consideration of the opportunity to participate in HealthSmart Advantage, LLC. (“HSA”) programs and/or use of fitness center (“FC”) facilities, I hereby assume all risks of injury, illness, death or other loss arising from or in any way relating to my participation in HSA programs and services and use of FC.
I hereby release, agree not to sue, and forever discharge. (CLIENT), and HSA (MANAGEMENT COMPANY) and their respective Affiliates* (as defined below) of and from any and all manner of claims, demands, actions, causes of action, liability, damages, claims for punitive or liquidated damages, claims for attorney’s fees, costs and disbursements, individual or class action claims, and demands of any kind whatsoever, I have or might have against them or any of them, whether known or unknown, in law or equity, contract or tort, arising out of or in any way relating to services, participation in HSA programs, use of the FC and loss of personal property, however originating or existing. This release shall be binding upon my heirs, personal representatives, administrators, executors, and assigns.
I understand that this release includes, without limitation, all injuries which may occur as a result of the following: my use of FC’s amenities and equipment in the FC facilities, my receipt of instruction and other services from HSA, or my participation in any activity, class, program, or instruction; the malfunctioning of any equipment; HSA’s (including independent contractors of or employees of HSA) for personal training, classroom instruction or specialty services, supervision; and my slipping and/or falling while in or on the FC’s premises, including locker rooms, bathrooms and hallways.
I further understand that any recommendations regarding exercise are entirely my responsibility and that I should consult a physician prior to undergoing any changes in exercise.
I understand, as a participant of the health and fitness program who is to be assessed and given the opportunity to participate in an exercise program at the FC, I will have the option to receive a bio-metric assessment (“BMA”, for which a separate waiver required).
I further understand HSA staff will question me about my health status, and I agree to complete a health history questionnaire. I certify the information I provide to HSA staff about my health and exercise history and current health status will be, to the best of my knowledge, complete and accurate, and I agree and understand it is my responsibility to inform HSA staff in the event of any change in my health or medical status. HSA shall treat information regarding my personal health and medical status as confidential. HSA shall not release such information without my written consent, except: to authorized HSA and CLIENT employees, agents, successors, and assigned contractors who we use to support our business; in connection with any HSA programs in which I participate; in connection with the sale, assignment, or other transfer of the business which the information relates; when applicable by laws, court orders or government regulations require us to do so; and to health care personnel for treatment purposes (including, for example, emergency assistance personnel). I understand that HSA may use or disclose to others information regarding my health for statistical analysis or other research purposes, provided that my name and other personally identifiable information will be removed from the information prior to such uses and disclosures.
I understand there are possibilities of injury or other complications, including but not limited to musculoskeletal injuries, cardiovascular trauma, neurological impairment, heart attack and even death, while completing an exercise program, while otherwise using the FC facilities, or while participating in any health and fitness program activities.
I understand use of the FC and participation in health and fitness program activities is strictly voluntary, is not required of employees of participating companies, and I may discontinue my participation at any time. I further understand HSA may revoke my privileges to use the FC or otherwise participate in assessment or other programs at any time, in its sole discretion. I agree to be bound by and obey all the rules and policies of the FC, HSA and HSA staff in my use of the FC and in my participation in the health and fitness program activities.
I understand at any time I may review this Release of Liability and Consent by requesting a copy from HSA staff. I agree if any portion of this form is held invalid, the remainder of this form will continue in full legal force and effect.
I (initial) understand that the fitness center is open and partially supervised from 6:00 am to 8:00 pm (subject to change without notice) Monday through Friday (excluding holidays) by professional staff (which may include: full and/or part-time staff, personal trainers, exercise instructors and massage therapists) and the fitness center may be monitored by a video surveillance system during normal operating hours listed above.