Lakeside Fitness Center Information & Membership Application

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Lakeside Fitness Center

Information & Membership Application

Thank you for your interest in joining the Lakeside Fitness Center in the Innovation Center, under

management of All Wellness Physical Therapy & Pilates. We get a lot of questions about how everything

works with the building’s facilities – hopefully this packet will answer all of your questions.

The Lakeside Fitness Center (the gym) in the Innovation Center is owned by the building and was built to

be a private amenity for all tenants. For only $10 per month you can have 24/7 access to the gym – just

bring your completed membership paperwork to All Wellness and your building key card will be given

permission to access the fitness center. Along with your membership you will receive other perks, such

as FREE and reduced price classes, FREE injury and fitness screenings, and deals from the other

practitioners in our office.

All Wellness is responsible for making sure all equipment is working properly and that the space is clean

and organized. We’re also here to listen to your feedback and requests. The following pages outline the

benefits that you’ll receive with you membership and assist you in signing up.

Don’t hesitate to email, call, or stop by!

Sincerely,

Laura M. Savard, Owner

802-863-9900

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Fitness Center Membership Perks!

 Auto renewing membership for 24/7 gym access – cancel at any time. Invite a friend! They will

enjoy the same benefits for $20 per month.

 $5/month locker rentals located next to the gym – cancel at anytime

 FREE & ½ priced fitness classes at All Wellness

Every month the calendar of classes will be posted in the gym and in your office – attend as many

classes as you want!

 FREE 15 minute injury screening with our board certified Doctor of Physical Therapy,

Emelia Brogna – Injured? Find out what to do next!

 FREE 30 minute Pilates fitness screening with Polestar Pilates trained Physical Therapist,

Joan Shaplin – This screening will assess your posture, core strength, balance, and alignment.

 Use All Wellness’ fitness room to stretch or have more floor space for your workout

 $10 off your first 60 minute therapeutic massage with Karla Henning, CMT – call 802.324.0125

to schedule

(originally $65, new clients only)

 ½ off your first energy healing session with Don DeMercurio – call 802.448.2473

to schedule

(originally $95,new clients only)

 FREE 45 minute acupuncture consultation with Shane Burras, L.Ac. – call 802.347.1834

to schedule

To take advantage of these deals, simply identify yourself as a

fitness center member at time of scheduling.

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MEMBERSHIP APPLICATION

Name: ____________ Date:

Address: __________ DOB:

City: _________________ State/Zip: _

Cell Phone: ____ Work Phone: Ext: _

Email Address: _______________________________________________________

I am applying as (circle one):

a. $10 - Building tenant; I work for ____________________________________

b. $20 - Guest; I am a guest of ________________________________________

Emergency Contact: ____________________ Phone: _

Medical Information:

Have you had or do you have any of the following conditions?

If so, please indicate date.

Stroke Asthma _

Hernia Diabetes _

Cardiovascular Disease High Blood Pressure

Muscular Injury/Condition Pregnancy

Skeletal Injury/Condition________ Trimester: _1

st

___2

nd

___3

rd

Surgery History of Fainting_

Other__________

If yes to any above, please explain: ________________________________________

_____________________________________________________________________

Fitness Goals:

What benefits would you like to achieve from your exercise program?



Body Fat/Weight Loss



Improve Body Tone



Improve Muscular Strength/Endurance



Improve Cardiovascular



Improve Sports Performance



Improve Flexibility

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RULES AND REGULATIONS

Use: Members shall use the facilities and related equipment solely for fitness training on the equipment provided. No person may use the Center unless they have signed an Informed Consent. This Center is open to members only - a member can be (1) any employee of a tenant in the Innovation Center, or (2) a guest of any employee with an access badge. Guest passes are limited to one per member and may be restricted to any amount that management deems appropriate. Guest memberships will be canceled if/when the building employee no longer works at the Innovation Center. All memberships are subject to fee increases and will be given notice prior to the increase. Management reserves the right to close the facilities, relocate them within the building, change their size, shape and/or equipment, and/or discontinue their use at any time. The Landlord has no obligation to provide these facilities, and does so only upon the express understanding that it can cancel the services and use of these facilities at any time.

Indemnification: By signing below, you acknowledge that the use of the facilities is at your own risk. You hereby indemnify and hold harmless the management, owners, and their agents for injury or loss for any reason regardless of fault.

Access: Wellness Center is badge access with trilogy lock security on the Locker Room doors. Members will be given the combination numbers for the Locker Rooms.

Hours of Operation: The Center may be used during normal operating hours which will be posted and are subject to change without notice. Management reserves the right to close any area of the club for new construction and/or repairs and maintenance without compensation to the membership. Management has the right to preempt facilities for special events. Management also reserves the right to close any part of the facility that it may consider dangerous for use.

Clothing: The minimum attire at the facility shall be gym shorts, tee shirts, socks and tennis shoes.

Any conventional exercise attire is permissible, including leotards and tights, warm up suits, etc. Sneakers, tennis shoes, or similar footwear must be worn at all times. Users of the Center must wear clean and appropriate attire when in transit to and from the Center, which may include, but not limited to, warm up suits and sweat suits.

Conduct: Any conduct that unreasonably interferes with the use or enjoyment of the Center or the equipment by other members, or disrupts or interferes with the normal, safe, orderly and efficient operation of the Center or the equipment is strictly prohibited. Radios, tape recorders or other similar equipment may not be used without headphones. Members in violation of this rule will be subject to immediate expulsion. Equipment Usage: Each individual is responsible for removing the weight plates that he/she has used on the plate-loaded machines and returning all plates, dumbbells, barbells, and other equipment to the proper storage places. Do not jerk, bounce, slam or drop weights. Also, one should wipe off equipment after use if excessive perspiration has occurred. Hand chalk is not permitted. Spotters and pinch-lock collars are required for free weights. Members must respect others’ need to use the equipment by limiting time on aerobic equipment to 30 minutes or less when others are waiting and by only sitting on the selected weight machines while actually doing the exercise. Out of order signs must be obeyed. No equipment can be used in a broken state.

Other Facilities: Lockers, showers and restrooms are provided. Management takes no responsibility for personal possessions left in these facilities. Locks on lockers are permissible, but all articles and locks must be removed when the tenant leaves the Center and cannot be left on overnight. Management reserves the right to remove any locks remaining when the Center closes each day. Note: there are a limited number of lockers available for rental.

Smoking: Smoking of any kind or any other consumption of tobacco products is strictly prohibited.

Food and Beverages Prohibited: Food and beverages (other than covered bottles of water) shall not be brought into the facility for consumption on the premises. Alcoholic beverages are strictly prohibited.

Maintenance: No member shall leave any litter, trash, debris, or articles of clothing at the Center or in its other facilities.

Solicitations and Petition: Solicitations for the sale of any product or services, or for charitable contributions, and petitions of any kind, are prohibited.

Notices, Complaints or Suggestions: Members must immediately notify the Management (863-9900) in the event they discover any unsafe or hazardous defect or condition relating to the Center or the equipment, any serious breakage, fire or disorder at the facility. Complaints or suggestions as to the operation, maintenance, services, or equipment at the Center are welcome. Such notices, complaints or suggestions should be sent to the Property Manager.

Violation of Rules: Repeated failure or refusal to comply with these rules and regulations may result in the loss of membership privileges.

Fees/Refund Policy – The monthly fee for employees of the Innovation Center is $10 per month; the fee for guests is $20 per month. Members may be charged a $30 deposit for an access badge, which will be refunded when returned. Memberships are nonrefundable, but can be canceled at any time by contacting Management (863-9900). Members who cancel their membership and sign up again at a later date will be charged a $25 reactivation fee.

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INFORMED CONSENT

I understand and acknowledge there are certain risks involved in physical exercise and

conditioning, and the use of the equipment and facilities offered by Lakeside Wellness Center. I

hereby release Fortieth Burlington LLC (Owner), Lewiston Two, LLC and its affiliates, its

tenants, and Gilbane Development Company (Property Manager) together with its operators,

agents, employees, consultants, and instructors, from any and all claims from injury or damage

that may be sustained by me from use of the premises or equipment, or as a result of the actions

or inactions of others, or from participating in the physical exercise of body conditioning from

which I have subscribed, regardless of the cause of such injury or damage.

I represent hereby that I am in good health and capable of participating in such a program, that

I will not do anything which will injure myself or others while engaging in such programs, and

will hold Fortieth Burlington LLC (Owner), Lewiston Two, LLC and its affiliates, its tenants,

Gilbane Development Company (Property Manager) harmless in connection with my

participation.

I hereby apply for membership to the Lakeside Fitness Center and if accepted, agree to abide

by the Rules and Regulations, and Informed Consent governing members outlined in this

packet.

Name (print): ____________________________________________________________________

Signature: ______________________________________________________________________

Date: ________________________________________________________________________

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PAYMENT INFORMATION

A fitness center membership is affordable and easy – your credit card will automatically be

charged on a monthly basis and your membership will remain active until you cancel.

FITNESS CENTER MEMBERSHIP - $10/month employee or $20/month guest

LOCKER RENTAL - $5/month

Yes_ No_

My locker # is __________

Please complete the card information below, which hereby authorizes the Lakeside Fitness Center to debit the following card for the above

monthly auto renewing membership. I may cancel my membership at any time by contacting All Wellness at (802)863-9900.

Name on Card: _______________________________________________ Type of Card (Visa, Discover, etc.): ______________________________ Card Number:__________________________________________________ Expiration Date: ____ ____________ CCV Code:_______________

Signature: _______________________________________________________________________ Date: ____/____/____

Lakeside Fitness Center Information & Membership Application