*Name
Email
Address
City
How did you hear about us?
Emergency Contact Name:
Phone:
Birthdate
ST
Zip
Emergency Number:
Please review the following rules, terms, and conditions of this contract. Your signature binds you to the
policies, rules and terms that you have received.
This Membership Agreement is between ________________________________[member (s)]
and Poolesville Athletic Club (PAC).
Membership Fee: I agree to pay Poolesville Athletic Club my first month dues pro-rated $ _______
and to be billed the 1st of each month $_________ for the duration of my membership. In
addition, I agree to pay the Member Enrollment fee of $________. This membership agreement
will remain in effect until I notify PAC in writing of cancellation.
WAIVER AND RELEASE
You have agreed to purchase a membership at a facility that allows you self-access to the fitness center.
As such, you are aware that there will be no staff supervision at times. You are also aware that if you are
injured, become unconscious, suffer a stroke or heart attack, that there will likely be no one to respond
to your emergency and this facility has no duty to provide assistance to you. Even though this facility is
equipped with surveillance cameras, it is likely that should you require immediate assistance, none will
be provided. We HIGHLY recommend that you have a workout partner accompany you while at
POOLESVILLE ATHLETIC CLUB, but it is entirely up to you. Initial______
Because physical exercise can be strenuous and subject to risk of serious injury, POOLESVILLE ATHLETIC
CLUB urges you to obtain a physical examination from a doctor before using any exercise equipment or
participating in any exercise activity. You (each member, guest or participant) agree that if you engage in
any physical exercise or activity, or use any POOLESVILLE ATHLETIC CLUB amenity on the premises or off
premises including a sponsored club event, you do so entirely at your own risk. You agree that you are
voluntarily participating in the use of this facility and assume all risks of injury, illness, or death. We are
also not responsible for any loss of your personal property. Initial______
This waiver and release of liability includes, without limitation, all injuries which may occur, regardless
of negligence, as a result of; (a) your use of all amenities and equipment in the facility and your
participation in any activity, class, program, personal training or instruction, (b) the sudden and
unforeseen malfunctioning of any equipment, (c) any dietary recommendations and (d) your slipping
and /or falling while in the club premises, including adjacent sidewalks and parking areas. Initial______
You acknowledge that you have carefully read this “waiver and release” and fully understand that it is a
release of liability. You expressly agree to release and discharge POOLESVILLE ATHLETIC CLUB, and all
affiliates, employees, agents, representatives, successors, or assigns, from any and all claims or causes
of action. You agree to voluntarily give up or waive any right that you may otherwise have to bring a
legal action against POOLESVILLE ATHLETIC CLUB for negligence, personal injury or property damage.
Initial______
POLICIES AND AGREEMENTS
1. This is a legal and binding contract that is valid from date of contract until canceled. This contract will
automatically renew for an additional 1 month term every 30 days, unless Member delivers to PAC written
notice of intent to cancel prior to the last day of the month member wishes to discontinue billing. If
membership is forfeited, terminated, or canceled for any reason, and thereafter a new application is filed
for reinstatement, a new Member enrollment fee must be paid.
2. Even if PAC facilities and services are not used, Member is still responsible for payment under this contract.
3. Guests will be charged a visit fee at current pricing and must register before using the club. Guests must be
accompanied by a member at all times.
4. Members will be required to check-in via the front door entry with their PIN ACCESS CODE before using the
club.
5. If a member access code is used and anyone other than that member enters the facility the member is
subject to a false entry fee of $25 and their access code will be deactivated from further use until the
problem is addressed.
6. If a member grants access to others by opening or holding the door open, the member is subject to a false
entry fee of $25 and their access code will be deactivated from further use until the problem is addressed.
7. Children under 16 are not permitted in the club without adult supervision.
8. Members and their guests agree to be responsible for any and all items loaned, rented, or made available
for use. Any items damaged, lost, or not returned will be charged to the member or guest. Replacement
costs will be determined by PAC. PAC is not responsible for any items lost, stolen, or damaged by the
member on the club premises.
9. Shoes and shirts must be worn at all times. Profane language must not be used. Smoking is not permitted.
10. Member acknowledges the right of PAC to add, delete, or change equipment and/or programs and
acknowledges the right of PAC to establish or change hours of operation and holiday closings if applicable.
11. A late charge of $10.00 per payment period will be assessed if Member's payment is received more than 5
days late and/or there remains an unpaid balance due to partial payments, unpaid payments, and/or
unpaid late charges or return charges. There will be a $25.00 charge for all returned checks and/or
electronic returns, and/or charge-backs due to insufficient funds.
12. Membership may be cancelled at any time at the sole discretion of management. Membership may be
immediately terminated for: {a} violation of any rule or regulation of the club; {b) conduct which is
prejudice to the welfare, good or character of the club; {c} failure to pay any charges due 60 days after
billing date. Membership is subject to acceptance of this application by the club. At such time, all unpaid
past dues shall become immediately due and payable.
13. PAC reserves the right to alter these policies, rules, and terms at any time, by giving members at least ten
day notice, posted in writing at the facility. PAC also reserves the right to alter, or amend, or terminate the
contract for any reason upon 30 days written notice.
NOTICE OF CONSUMER RIGHTS
1. Our health club registration number is E3793
2. Our facility is not required to carry a performance bond under the Maryland Health Club Services Law since
we do not collect more than three months payment in advance.
3. Our facility does not charge or collect enrollment fees over $200.00.
4. If you become disabled for at least 3 months during the membership term and that disability is confirmed in
writing by a physician, you have the right to an extension of this contract.
5. If the facility is closed for a month or more, you are entitled to your choice of either an extension of the
contract or prorated refund, except if the closing is not the fault of this facility, in which case the choice of
remedy the facilities.
6. This Notice of Consumer rights is an integral part of the Application and Contract for membership.
7. Under Maryland State and Montgomery County Law, you can cancel this contract without any obligation
within three business days after signing it and receive a full refund. You must notify PAC of your decision to
cancel this contract by certified mail or by written notice delivered to the Club.
Should any part of this agreement be found by a court of law to be against public policy or in violation of any state
statute or case precedence, then only that wording is removed and the remainder of this agreement will remain in
full force. I have read and understand the foregoing.
_______________________________________________________________
Print Name
______________________________________________
Signature
_________________
Date
Poolesville Athletic Club
17610 West Willard Rd / Poolesville,
MD (240)489-3223
