PTSP Membership Paperwork

PTSP Member Information

Enrollment Fee: $99/month. No contract, cancel anytime.
Name*

First NameLast Name
Today's date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Emergency Contact
Phone #
Relationship
How did you hear about us?*
Member Fitness Goals

Please list any activities that you would like to be able to do as a result of your strength consultation and program design.
Task/Activity
Duration/How Often
By When
Task/Activity
Duration/How Often
By When
Other Goals?
Monthly Dues: Monthly dues for the PTSP Membership are $99 per month. Dues will be collected electronically on the date of signup every month. In the event Physical Therapy San Pedro is unable to collect payment electronically, the member will be notified and payment must be made by other means in order to maintain membership privileges.

The member is responsible for canceling monthly memberships at least 24 hours before scheduled billing date, and understands that the agreement will be automatically renewed until canceled. Management has the right to suspend and/or terminate any membership for non-payment of dues, fees, or for behavior inimical to the enjoyment of Physical Therapy San Pedro by all members and staff for any reason deemed sufficient in the sole discretion of management. In the event that non-payment exceeds 30 days, the member understands that their membership will be terminated.

Waiver: In consideration of the fee paid, participant understands that there is a risk of personal injury in the course of instruction and, with this knowledge, agrees to assume the risk of any injury and damages while inside the facility of Physical Therapy San Pedro. Participant further agrees to strictly obey trainers and observe safety rules.

I understand that Physical Therapy San Pedro will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.

Photographs taken during the time the participant is in the facility will be used for postural comparison purposes and as educational tools. By signing below I consent to the use of these photographs in a professional manner.

I have read and understand this release and agreement and agree to its provisions. I am not under the influence of any drugs, alcohol, or other intoxicants. I am not suffering from any illness or incapacity. I am over 18 years of age. (If not over 18 years of age, a parent or guardian must sign)
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

PTSP Member Information

Member Fitness Goals