Client Profile and Health History
Please take a moment to answer these questions honestly and accurately.
Current Height: Current Weight: Goal Weight:
How many hours of sleep do you get each night?
Describe your job.
Sedentary Active Physically demanding
How many hours, on average, are you in your car per day?
What brings you into Jackson State of Fitness?
1.
2.
3.
When do you like to exercise?
Morning Afternoon Evening
What activities are you currently involved in?
How often do you exercise?
1-2 X per week 3-4 X per week 5 + per week
Rate your current nutritional habits.
Poor Good Excellent
My current diet could be described as (check all that apply):
Do you feel your energy drop during the day? YES NO
Please describe what your fitness goals are and what you have done in the past.
Please answer the following questions honestly: If Yes, please explain.
Do you currently have or have you recently had any of the following?
Please list any other important information that would affect your training program.
I authorize Jackson State of Fitness to bill my credit card for monthly membership fees along with any additional late fees or cancellation fees.
ASSUMPTION OF RISK AND RELEASE OF LIABILITY
In consideration for the permission granted me to use facilities, including but not limited to any gym, locker room, outdoor field and trails (“Facilities”), and to participate in wellness activities (“Activities”), on Jackson National Life Insurance Company (“Jackson”) owned and/or leased premises, I represent and agree as follows:
1. I am under no restrictions, physical or otherwise, not consistent with my use of Facilities or participation in Activities. I am solely responsible for my health and well-being at all times while using Facilities and participating in Activities.
2. My use of Facilities and participation in Activities is voluntary and not a condition of my employment.
3. I use Facilities and participate in Activities understanding the risk of personal injury, including disability and death. I assume full responsibility for any known and unknown risk of personal injury, including disability and death, property damage, or loss that I may suffer while I use Facilities and participate in Activities.
4. I will use Facilities and participate in Activities only on my personal time.
5. I will abide by any rules, regulations, and policies that Jackson establishes or approves, affirmatively or by default, applicable to Facilities and Activities.
6. Jackson, without prior notice or warning, may revoke at any time my permission to use Facilities and to participate in Activities. Permission will be automatically revoked upon termination of my employment.
7. On behalf of myself, my personal representatives, heirs, executors, administrators, agents, successors and assigns, I hereby forever release Jackson, Jackson’s parent company and its subsidiaries and affiliates, and their employees, officers and directors (collectively, “Releasees”) from any and all liability and claims of any kind or nature arising out of or related to any loss, damage, or injury, including disability and death, that I sustain while I use Facilities and/or participate in Activities. I will defend, indemnify, and hold harmless the Releasees from and against claims, liabilities, demands, fines, actions, proceedings, orders, decrees, and judgments of any kind or nature and from and against all costs and expenses, including reasonable attorney’s fees, resulting from or in connection with my use of the Facilities and participation in Activities.
8. Releasees’ waiver of any noncompliance with any term of this Assumption of Risk and Release of Liability shall not constitute a waiver of any of its terms in other circumstances.
9. This Assumption of Risk and Release of Liability shall be governed by and construed according to the laws of the State of Michigan, excluding its choice of law provisions.
10.This Assumption of Risk and Release of Liability documents the entire agreement regarding its subject matter and supersedes all prior and contemporaneous agreements, understandings, representations, and warranties, both written and oral, with respect to its subject matter. If any term of this Assumption of Risk and Release of Liability is invalid and unenforceable in any jurisdiction, that invalidity and unenforceability shall not affect any other term. This Assumption of Risk and Release of Liability is binding on and shall inure to the benefit of any respective successors, assigns, and heirs.
I HAVE READ THIS ASSUMPTION OF RISK AND RELEASE OF LIABILITY AND FULLY UNDERSTAND THAT I AM RELEASING POTENTIAL CLAIMS, AND I VOLUNTARILY AGREE TO ITS TERMS.
Signed and Dated on .
Name:
Signature:
Bailey/Zeus, LLC d/b/a,
“STATE OF FITNESS”
WAIVER AND RELEASE OF LIABILITY
READ FULLY AND CAREFULLY
In consideration of Bailey/Zeus, LLC, d/b/a “State of Fitness” and its owners, members, affiliates, employees, officers, representatives, independent contractors, subcontractors, and/or agents (collectively “State of Fitness”) allowing me, to utilize and/or participate in various health and physical fitness activities, among other things, offered by State of Fitness, including but not limited to: services, equipment, food, drinks, classes, and/or other instruction (collectively, the “Club Activities”), I, , on behalf of myself, my personal representatives, my heirs, and my assigns, agree to all of the following:
ACKNOWLEDGEMENT OF RISKS
I fully and completely understand and acknowledge that:
(a) risks, dangers, and hazards exist (foreseeable and unforeseeable) in my use of and/or participation in the Club Activities;
(b) my use of and/or participation in the Club Activities may result in injury, illness, or other harm to me including but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, eye injury, blindness, heat stroke, heart attack, death and/or other ailments that could cause serious disability (collectively, the “Injuries”);
(c) these risks, dangers, hazards and Injuries may be caused by or arise from:
(i) acts, omissions, or negligence (including gross negligence) of State of Fitness,
(ii) acts, omissions, or negligence of other users of or participants in the Club Activities,
(iii) acts, omissions, or negligence of others, and/or
(iv) accidents, breaches of contract, forces of nature, or other foreseeable and/or unforeseeable causes of any nature whatsoever; and
(d) by my use of and/or participation in the Club Activities, I am fully aware of and acknowledge the existence of all such risks, dangers, hazards, and Injuries, foreseeable and unforeseeable, enumerated and unenumerated, and outlined in (a) through (c) above (collectively, the “Risks”) and have voluntarily agreed to participate in the Club Activities in spite of all such Risks.
ACCEPTANCE/ASSUMPTION OF RISK AND RESPONSIBILITY
I hereby voluntarily and unconditionally assume and/or accept any and all Risks that are related in any way whatsoever to (or are in any way connected with) my use of and/or participation in the Club Activities. I further voluntarily and unconditionally assume and/or accept all responsibility, of any form, type, or nature (e.g., monetary, non-monetary, legal, equitable, etc.) for any and all losses and/or damages that I may suffer that are related in any way whatsoever to (or are in any way connected or associated with) the Risks and my use of and/or participation in the Club Activities (collectively, the “Responsibilities”). My unconditional voluntary acceptance and assumption of the Risks and Responsibilities shall apply without limitation regardless of whether any losses and/or damages I may suffer are caused in whole or in part by the negligent acts, omissions, or other conduct of State of Fitness, or by any other person.
WAIVER, RELEASE, INDEMNITY, AND HOLD HARMLESS
I hereby voluntarily and unconditionally agree to release, waive, discharge, indemnify, and otherwise hold State of Fitness harmless from and against any and all liabilities, claims (including but not limited to claims for contribution or indemnification), demands, actions or rights of action, losses, damages, and/or defenses (including, without limitation, attorney’s fees incurred by State of Fitness as a result) (collectively, the “Claims”) that are related in any way whatsoever to (or are in any way connected or associated with) my use of and/or participation in the Club Activities (collectively, the “Release”). My voluntary and unconditional Release shall also include, but is not limited to, any and all Claims that are related in any way whatsoever to (or are in any way connected or associated with) the Risks and/or Responsibilities (including but not limited to any and all Claims for bodily injury, property damage, wrongful death, loss of services, Injuries, or other loss/damage of any type or nature). I specifically understand that by executing this document and agreeing to this Release, I am releasing, waiving, discharging, indemnifying, and otherwise holding State of Fitness harmless from any and all Claims that I may presently or in the future have as a result of (or arising out of) the Club Activities, the Risks, the Responsibilities, and/or the negligent acts, omissions, or other acts (or failures to act) of State of Fitness. Nevertheless, it is my specific intent to Release State of Fitness from and against any and all Claims of any kind to the absolute maximum extent possible under Michigan law, and this paragraph, as well as the rest of this document, shall be interpreted (and reformed to reflect such intent if necessary) accordingly.
AGREEMENT TO ARBITRATE
Any controversy or claim arising out of or relating to this document, or the breach thereof, shall be settled by arbitration administered by the American Arbitration Association in accordance with its Commercial (or other) Arbitration Rules (including the Optional Rules for Emergency Measures of Protection), and a judgment of any circuit court (or similar court with jurisdiction) may be rendered upon the award made pursuant to this agreement to arbitrate.
SEVERABILITY
It is my desire and intent that the words, terms, provisions, covenants, and remedies contained in this document shall be enforceable to the fullest extent permitted by law. If any such word, term, provision, covenant, or remedy of this Agreement or other application thereof to any person or circumstance shall, to any extent, be rendered invalid or unenforceable in whole or in part by a court or agency of competent jurisdiction, ,then such word, term, provision, covenant, or remedy shall be construed in a manner so as to permit its enforceability under the applicable law to the fullest extent permitted by law. In any case, the remaining provisions of this Agreement or the application thereof to any person or circumstance other than those to which they have been held invalid or unenforceable, shall remain in full force and effect.
ENTIRE AGREEMENT
All agreements, understandings, and representations of any kind by and/or between the parties are embodied and expressed herein, and the terms hereof are contractual and not a mere recital. There are no other agreements, understandings, representations, inducements, and/or undertakings of any kind except as expressly set forth herein. All prior and contemporaneous negotiations and agreements between the parties on the matters contained in this document (if any) are expressly merged into and superseded by this document. In agreeing to sign, execute, and be bound by the terms and conditions of this document, I have not relied upon, and specifically disavow reliance on, any statement, representation, warranty, or agreement of State Of Fitness except for those expressly contained in this document. There are no conditions precedent to the effectiveness of this document.
EFFECT OF SIGNATURE
MY SIGNATURE BELOW INDICATES THAT:
(1) I HAVE READ THIS ENTIRE DOCUMENT AND THAT I UNDERSTAND IT IN ITS ENTIRETY;
(2) I HAVE BEEN GIVEN THE OPPORTUNITY TO REVIEW THIS DOCUMENT WITH AN ATTORNEY OF MY CHOOSING;
(3) I UNDERSTAND THAT I AM WAIVING AND RELEASING SIGNIFICANT AND IMPORTANT RIGHTS HEREUNDER; AND
(4) IT IS MY INTENTION TO EXEMPT AND RELIEVE STATE OF FITNESS FROM LIABILITY, CLAIMS, RISKS, RESPONSIBILITIES, INJURIES, ETC. AS DETAILED IN THIS DOCUMENT.
It takes 24 hours for your badge to activate from the time you sign up and membership has been confirmed. Memberships will be confirmed during Jackson workdays; Monday – Friday during 8:30am-5:00pm. If you have signed up Saturday or Sunday your badge will be updated the following Monday. You can still access the Fitness Center when trainers are present between 6:30am-7:15pm by providing verification of membership.
Membership to JSOF is for Jackson associates only; at this time, it does not include contract and contingent workers.