Ryfields Gym Membership form
Please complete this form to set up your membership.
Date of Birth
Gym Plus (£32.50 per month DD)
Pay Monthly Gym (£12.50 per month DD)
12 month up front Gym (£100)
Other (by discussion)
We're not doctors but legally we need to check a few things with you before you start training. Depending on the severity of any issues, we may advise you check with a doctor before training, although, if you're happy to get going, we won't stop you.
Please tick all that apply to you
Your doctor has said that you have a bone or joint problems, such as arthritis that has been aggravated by exercise
You have high blood pressure?
You have low blood pressure?
You have Diabetes Mellitus or any other metabolic disease?
Your doctor has said you have raised cholesterol (serum level above 6.2mmol/L)?
Your doctor has said that you have a heart condition and that you should only do physical activity recommended by a doctor?
You ever felt pain in your chest when you do physical exercise?
Your doctor currently prescribing you drugs or medication?
You have suffered from unusual shortness of breath at rest or with mild exertion?
There is a history of Coronary Heart Disease in your family?
You often feel faint, have spells of severe dizziness or have lost consciousness?
You currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)?
You currently smoke?
You currently do NO exercise
You are, or there is, any possibility that you might be pregnant?
You know of any other reason why you should not participate in a physical activity program?
As a Ryfields Gym member we are able to offer you a free membership to our discount club. This could entitle you to a reduction on your household bills, discounts on days and meals out and reduced prices on your Utility services including Broadband and Gas / Electricity.
Do you get an electricity and / or Broadband bill?
Would it be OK if it was less
We can help you earn some extra money part time too... Do you want some extra spending money each month?
I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death.
Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.
I understand the Gym may be unstaffed at times and personally accept the risk of training unsupervised.
I understand that by submitting my bank details above, a Direct Debit will be set up and collected until cancelled and in the event it does not get paid, Ryfields Gym may refuse access to the Gym.
Please type your name to confirm the above
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