LIFETIME FITNESS: 2004-2005



University Of Illinois

Lifetime Fitness Program

Freer Hall, 906 S. Goodwin Avenue, Urbana, IL 61801

Phone: (217) 300-1175 Fax: (217) 244-7322

Please check one:

New Member _______

Returning Member _______

Name: ________________________________________________________________________________________ __

First Middle Last

Address: ______________________________________________________________________________________

Street Address

________________________________________________________________________________________

City State Zip

Phone: ( ) ( ) ( ) ___________

Home Cell Other

E-mail: _________________________________________ I would like to receive LFP info by email? YES NO

Birthday (Month/Day/Year): Sex: Race:

If applicable, please check: UIUC Retired ________UIUC Current ________ OLLI Member ________

Silver Sneakers Member________ Health Alliance Medicare ___________

Physician: _____________________________________________________________________________________

Name Phone Number Hospital

Current Medications: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies: ______________________________________________________________________________________

In case of an emergency, please list a LOCAL contact:

Name: ______________________________________________ Relationship: _______________________

Phone: ( ) ( ) ( )

Home Cell Other

Additional Emergency Contact Information:

Name: ______________________________________________ Relationship: ________________________

Phone: ( ) ( ) ( )

Home Cell Other

Name: ______________________________________________ Relationship: ________________________

Phone: ( ) ( ) ( )

Home Cell Other

Lifetime Fitness Program Legal release

I hereby request the Board of Trustees of the University of Illinois to accept me for admission to its Lifetime Fitness Program which is administered by its Department of Kinesiology, and in consideration of such acceptance and admission, I hereby fully and completely release and discharge the said Board of Trustees of the University of Illinois, its officers, agents, staff members or employees, and each of them, from any and all claims and demands of whatever nature I may hereafter assert against said public corporation, its officers, agents, staff members or employee, or any of them, on account of any accident, injury, or illness which I may sustain while in attendance, and any and all consequences thereof.

I acknowledge that I have read the purpose, scope, and nature of the University of Illinois Lifetime Fitness Program, and that I understand the nature of the program and the risks involved.

I acknowledge and affirm that I have been examined by my personal physician for the purpose of entering said Lifetime Fitness Program, and that, to the best of my knowledge and belief, I have no physical illness or weakness that would increase the risk to me of participation in this program.

In consideration of my acceptance and admission to said Lifetime Fitness Program, I hereby assume all risks and hazards to me, probable and improbable, associated with participation in said Program.

Name (Please print)

Signature Date

*This release form is for participation in the Lifetime Fitness Program and does not serve as an informed consent for research activities conducted in concert with the program. Prior to your involvement in specific research studies you will be fully informed of the nature of the research activities, the measurements to be made, the requirements of the research, as well as the potential risks and benefits to you pertaining to participation in such activities.

Members of the Lifetime Fitness Program have two options to choose from:

Option 1

Full access includes:

•all cardio and resistance machines and weights

•indoor track

•pool access

•all specialty group fitness classes though LFP

*This option is typically for those that want to participate in all our LFP fitness classes

Option 2

Limited access includes:

•all cardio and resistance machines and weights

•indoor track

•pool access (M-F 11am-2pm ONLY)

•only basic LFP group fitness classes (7am class only; stretch)

*This option is typically for those that choose to work out on their own

_____ I have enclosed a check

_____ I have paid with credit/debit card

_____* I am a member of OLLI and receive a 20% discount off these prices

Silver Sneakers Members

• Option 1 ($10/month)

• Option 2 (No cost)

All other Members

• Option 1 ($30/month)

• Option 2 ($20/month)

_____ I have had medical clearance to participate in the program within the last 12 months or will obtain it prior to the first week of the program.

*Please make checks payable to: Univ. of Illinois-LFP

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