IDRA Fitness Center Application
Member No. __________________ Amount Paid _____________ Date __________________ Membership Application Fitness Application Payroll Allotment Employment OPM OAS GSA STATE OTHER __________________ |
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| IDRA FITNESS CENTER REGISTRATION PACKET
Each Fitness Center member must maintain a current IDRA membership. Smoking is not permitted in the Fitness Center. Food or beverages may not be consumed at or brought into the Fitness Center. Neither street shoes nor black-soled shoes of any kind are permitted on the hardwood gym floor, with the exception of black-soled running shoes when used only for jogging laps or passing through the area. No bare feet allowed outside of locker rooms. Members must secure prior consent from the Fitness Center staff before bringing a guest (ask staff for a copy of guest policy). Shorts or warm-ups and a shirt must be worn when leaving and re-entering the Fitness Center and in any part of the Interior building. Upon exiting the building to go jogging, etc., and upon return, all individuals must use the designated exit. IDRA reserves the right to sever all membership privileges for participants other than DOI employees, if at any time it feels that such participation is interfering with service to Interior employees. Should this occur, IDRA will issue a prorated membership refund to all affected employees. Members whose memberships expire must empty their lockers within 10 days of expiration or have their lock cut and locker contents disposed of by the Fitness Center staff. Members and guests are fully responsible for personal items that are lost, stolen, or damaged at the Fitness Center. Clothing with belts, buckles, zippers or other features judged by the staff to be potentially destructive to upholstery or other Fitness Center equipment is not permitted. Towels are permitted in the weight room; all other personal items including gym bags are prohibited. Shirts must be worn in the weight room and clothing must be dry. Instruction, by appointment, in use of equipment together with a medical questionnaire and appropriate clearance is required prior to use of the weight room. Members and guests may not display actions that the Fitness Center staff deems unsportsmanlike or rude, or misuse, move or alter any portion of the Fitness Center environment or property. Members using payroll allotment MUST REMAIN MEMBERS FOR AT LEAST 90 DAYS. Exceptions are made for persons who transfer jobs or who can no longer exercise for medical reasons (documentation from supervisor or doctor required). I have read the above rules and regulations pertaining to my use of the IDRA Fitness Center. I will comply with said requirements as well as all other posted rules and regulations with the understanding that if I do not, my membership privileges and all membership dues will be forfeited. Signed____________________________________ Date___________________ INFORMED CONSENT WAIVER I, the undersigned, wish to participate in the fitness program as offered by the IDRA. I certify that I am physically able to participate in any activities in which I will take part. I have a reasonable basis for this opinion due to examination and/or consultation with my physician. I also certify that I will use good judgement while exercising and will not overexert. I recognize that I am responsible for knowledge of my own state of health, and I will advise the fitness staff of any health problems related to exercising. I understand that participation in some or all fitness center activities may be denied me for health reasons at the discretion of the Fitness Center staff. I realize that any time one engages in physical activity there are inherent dangers. I therefore accept any and all responsibility and assume the risk of any and all injury or damage to my person which may arise, whether directly or indirectly as a result of my participation in the fitness program, or as a result of the prescriptive advice I receive. I hereby release and hold harmless from any liability whatsoever the IDRA, as well as its affiliates, directors, officers, employees, and representatives. I also agree to abide by the rules and regulations as established by the IDRA with the understanding that violation of such rules may result in withdrawal of my privilege to utilize the fitness facility or engage in the prescribed fitness program. I certify that I understand and agree to the contents of this waiver. Signed ____________________________________ Date __________________
Witness __________________________________________
MEDICAL HISTORY/PHYSICAL ACTIVITY QUESTIONNAIRE Privacy Act Statement P.L. 93-579. Authority: 5 U.S.C. Section 522a. Those Fitness Center members who wish to use the weight room and/or complete the Fitness Testing & Exercise Prescription Program are required to complete this questionnaire. This information is used by the staff to help develop a safe and effective individual exercise program, and as a screening device to prevent members from engaging in unsafe activities. The information in this questionnaire will be kept confidential, however it may be transferred in an anonymous form to outside health/fitness authorities for consultation purposes or for use in research. Disclosure of this information is on a voluntary basis. Name __________________________________________ Sex __________ Age _________ Last First Home Address _________________________________ City ________________ Zip ______ Home Phone ___________________________ Work Phone ___________________________ Your Occupation _____________________________________________________________ In Case of Emergency contact ______________________________ Phone ________________ Your personal physician ___________________________________ Phone _______________ Has a physician ever indicated that you must limit your physical activity? If yes, please explain _______________________________________________________________________ _______________________________________________________________________ Do you ever feel pain or a tight squeezing sensation in your chest? If yes, please explain ________ __________________________________________________________________________ Have you ever suffered from dizzy spells? If yes, please explain __________________________ __________________________________________________________________________ If you are presently using any type of medication, please complete the next two lines. If not, continue on third line below. Name of Medication ________________________ Reason for taking ______________________ Daily dose ___________________________ Duration of use ____________________________ What do you consider to be an ideal weight for you? ___________ Present weight? ___________ Your highest weight? _____________ How tall are you? _____________ Do you consider yourself overweight? _____________ If so, how many pounds? _____________ Do you presently have or have you in the past encountered lower back problems? If so, please describe in detail __________________________________________________________________ _______________________________________________________________________ If any of the following conditions presently apply to you, please indicate with a check.
Please list chronic or recent ailments, including sprains, muscular injuries, pains, stiffness, limitations in range of movement, back problems, or other persistent difficulties. Precise site of difficulty Description of the problem 1. 2. 3. 4. Please indicate the quantity of exercise you engage in during your job: Very little _______ little _______ moderate _______ active _______ very active _______ Please indicate the quantity of exercise you engage in during your leisure: Very little _______ little _______ moderate _______ active _______ very active _______
IF YOU WOULD LIKE ASSISTANCE IN DESIGNING YOUR EXERCISE PROGRAM, PLEASE COMPLETE THE INFORMATION BELOW. IF NOT, PLEASE TURN TO THE ATTACHED PHYSICIAN CONSENT FORM. If you are presently involved in any physical or recreational activities, please fill in the following: Activity Times Per Week Duration Per Session Rate the improvements you would like to see from highest priority (1) to the lowest priority (10): Increased strength _____ Decreased waistline _____ Increased endurance _____ Loss of fatigue _____ Increased breathing _____ Loss of stress _____ Increased flexibility _____ Improve diet habits _____ Decreased body weight _____ Other _______________ In your own words, why are you starting this fitness program? ______________________________ ________________________________________________________________________________ Please check the type of fitness activity you are most interested in for your program. You may check more than one. Weight training _____ Walking _____ Structured fitness class _____ Stationary cycling _____ Jogging _____ Other _______________ How many days per week do you plan to use the Fitness Center? __________ How much time per workout for the above (excluding travel and changing clothes)? __________ Would you consider supplementing your program with exercise at home? __________ If answer to previous question is yes, how many days? __________ and for how long each day? __________. Do you have access to any equipment or facilities other than the Fitness Center? _____ If so, describe ____________________________________________________________ ________________________________________________________________________ PHYSICIAN CONSENT FORM Some individuals are required to have a physician’s approval on this form prior to joining the Fitness Center based on information in the attached questionnaire. When you submit the completed questionnaire, the Fitness Center staff will advise you on this. Please refer questions on this requirement to the staff on 343-5756. Dr. __________________________, _____________________________ has expressed an interest in participating in the IDRA Fitness Program. This program will offer Fitness Classes and individualized exercise programs. The Fitness Classes have an aerobic emphasis, but also incorporate a quantity of flexibility and muscular strength work. The individual exercise program is created following the completion of a series of evaluative tests, which are marked by examination of five fitness parameters. The tests include: a sub-maximal bicycle ergometer test for determining aerobic capacity; a flexibility test done in the sit and reach style; a body composition analysis performed with skin fold calipers; a muscular strength test administered with Isotonic Weight equipment; and a muscular endurance test which examines the number of situps an individual can perform in a one minute trial. As a screening device, your patient has completed a Medical History Questionnaire indicative of his past and present medical history. The assignment of this individual to an exercise program is dependent upon receipt of your approval. With respect to the applicant, please check the following:
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