Louisiana Athletic Club Membership Application Online membership application based on the Louisiana Athletic Club Membership Application and Agreement. 1Membership2Primary Member3Additional Members4Payment Preference5Membership Agreement6Waiver of Liability7PAR-Q8Electronic Signature CommentsThis field is for validation purposes and should be left unchanged.Louisiana Athletic Club Membership Application Please complete the application below. Sensitive billing information, including full bank account or credit card details, will be completed through a secure payment process after your application is reviewed.Club Location(Required)Pineville – 1135 Expressway DriveAlexandria – 1804 MacArthur Drive, Suite B-304Membership Type(Required)SingleCoupleFamilyCorporate / SeniorMembership qualifications are subject to Louisiana Athletic Club policies.Agreement Type(Required) 12-Month Month-to-Month Other Other Agreement Type Primary Member InformationFirst Name(Required)Middle NameLast Name(Required)Date of Birth(Required) Gender(Required)FemaleMalePrefer not to answerEmail Address(Required) Cell Phone(Required)Home Address(Required)City(Required)State(Required)ZIP Code(Required)Place of EmploymentBusiness PhoneEmergency ContactEmergency Contact Name(Required)Emergency Contact Phone(Required)Relationship(Required) Additional Member InformationComplete this section for Couple, Family, or other memberships that include additional members.Member 2Member 2 Full NameMember 2 Date of Birth Member 2 GenderFemaleMalePrefer not to answerDependent 1Dependent 1 Full NameDependent 1 Date of Birth Dependent 1 GenderFemaleMalePrefer not to answerDependent 2Dependent 2 Full NameDependent 2 Date of Birth Dependent 2 GenderFemaleMalePrefer not to answerDependent 3Dependent 3 Full NameDependent 3 Date of Birth Dependent 3 GenderFemaleMalePrefer not to answerDependent 4Dependent 4 Full NameDependent 4 Date of Birth Dependent 4 GenderFemaleMalePrefer not to answerRestrict dependents from charging to the membership account? Yes No Payment Preference For your protection, this form does not collect full bank account, routing, Social Security, or credit card numbers. Louisiana Athletic Club staff will provide a secure way to complete billing setup.Preferred Payment Method(Required) Checking Account / ACH Credit or Debit Card Pay at Club / Contact Me Bank NameBank name only. Do not enter an account or routing number here.Payment and Fee Acknowledgments(Required) I understand that monthly dues may be drafted between the 1st and 5th of each month after secure billing authorization is completed. I acknowledge the non-refundable annual enhancement fee of $25, due at sign-up and charged annually thereafter. I understand that a $2 monthly card processing fee may apply when paying by credit or debit card. 12-Month Contract Agreement I understand that I am selecting a 12-month contract and am responsible for monthly dues for the full 12-month period. After the initial term, the membership automatically converts to month-to-month and continues until the Club receives the required written notice of cancellation. Cancellation timing and dues responsibility are governed by the Club's current written cancellation policy.Month-to-Month Contract Agreement I understand that I am selecting a month-to-month contract. I must provide the required written notice to cancel and remain responsible for dues through the effective cancellation date under the Club's current written cancellation policy.Membership Terms and Conditions By applying for membership, I agree to follow Louisiana Athletic Club policies and procedures, as amended from time to time. I understand that membership fees may be subject to change, accounts must remain current, returned payments may be assessed a fee, and the Club may terminate membership for violations of Club policies or false information. I understand membership may not be sold, assigned, or transferred. I acknowledge the cancellation and relocation provisions described in the membership application, including the requirement for written notice. I understand that signing this application does not replace the complete Membership Terms and Conditions and Club Policies provided by Louisiana Athletic Club.Membership Agreement Acknowledgment(Required) I have reviewed the applicable agreement type and understand the membership commitment and cancellation requirements. I have received, reviewed, or been given access to the complete Membership Terms and Conditions and Club Policies. I confirm that the information submitted in this application is accurate and accept financial responsibility for all individuals included on the membership. Waiver of Liability, Release and Assumption of Risk I understand that attendance at or use of Louisiana Athletic Club facilities, equipment, health or advisory services, programs, and activities may involve risks of injury, death, illness, property loss, theft, or other damages. These risks may include, but are not limited to, exercise, fitness equipment, weight lifting, sports, swimming, pools, locker rooms, steam rooms, childcare, environmental conditions, contagion, and other Club activities or facilities. On behalf of myself and my permitted guests, I voluntarily assume these risks and release Louisiana Athletic Club and its owners, managers, officers, directors, employees, agents, affiliates, contractors, representatives, volunteers, successors, and assigns from claims connected with attendance at or use of the Club, to the extent permitted by applicable law. I represent that I am physically fit to participate in the activities I undertake and understand that Club evaluations or recommendations are not a substitute for medical advice from my physician. I consent to photographs, video, or other media coverage of me while participating in Club activities.Waiver Acknowledgment(Required) I have read and understand the Waiver of Liability, Release and Assumption of Risk. I voluntarily accept and assume the risks associated with participating in Louisiana Athletic Club activities and using its facilities. I understand that I am waiving valuable legal rights to the extent permitted by law. PAR-Q Health Questionnaire Please answer each question honestly. A “Yes” response does not automatically prevent membership, but you should consult your physician before becoming more physically active or completing a fitness assessment.Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?(Required) Yes No Do you feel pain in your chest when you do physical activity?(Required) Yes No In the past month, have you had chest pain when you were not doing physical activity?(Required) Yes No Do you lose your balance because of dizziness, or do you ever lose consciousness?(Required) Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity?(Required) Yes No Is your doctor currently prescribing medication for your blood pressure or heart condition?(Required) Yes No Do you know of any other reason why you should not do physical activity?(Required) Yes No Important: Because you answered “Yes” to one or more questions, please consult your physician before becoming more physically active or completing a fitness assessment. Tell your physician which questions you answered “Yes” to.PAR-Q Acknowledgment(Required) I have read, understood, and completed this questionnaire, and my questions have been answered to my satisfaction. Electronic Signature and Final Authorization Typing your name below and submitting this form constitutes your electronic signature and confirms your agreement to the acknowledgments contained in this application.Primary Member Electronic Signature(Required)Type your full legal name.Date Signed(Required) Parent or Legal Guardian Electronic SignatureRequired when the primary applicant is under 18.Final Confirmation(Required) I certify that the information provided is true and complete to the best of my knowledge. I agree to the membership terms, payment acknowledgments, waiver, and health questionnaire statements included in this application. I understand that membership is subject to review and acceptance by Louisiana Athletic Club.
