Juanita Nielsen Gym

Juanita Nielsen Gym

Pre-exercise health form
Your details
Contact name*

Given nameFamily name
Preferred name

Given nameFamily name
Date of birth*

DayMonthYear
Date
Email*
How do you describe your gender?*

WomanManNon-binaryI don't knowI prefer not to answerI use a different term (please specify)
Are you are aged from 16 to 18 years*

YesNo
Name of parent/guardian*

Given nameFamily name
Contact number*
Address*

Street Address

Street Address Line 2

SuburbState / Province

Post code
Would you like to tell us more about yourself – this information will help us improve our programs and services at the centre for our diverse communities.

YesNo
Do you speak a language other than English at home?

YesNo
Languages
Are you an Aboriginal or Torres Strait Islander person?

YesNo
Do you identify as a person with disability?

YesNo
Do you identify as a person with a mental health condition?

YesNo
How do you describe your sexual orientation?

LesbianGayBisexualQueerHeterosexual (Straight)I don't knowI prefer not to answerI use a different term (please specify)
Note: If you answer yes to any of the questions below, you’re required to seek medical clearance/approval to undertake physical activity/exercise in our centre.

If you have not been physically active and/or aged 60 years and over we recommend you consult a medical professional before participating in fitness activities.

Please indicate if you have or have ever had any of the following conditions.*

	Yes	No
Heart condition (for example, heart attack, stroke, angina, heart murmur)?
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
High blood pressure?
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
Severe dizziness or feeling faint during exercise?
Have you been hospitalised in the last 6 months?
Are you pregnant?

Terms and conditions
Gym memberships
- The City of Sydney reserves the right to change conditions of membership, gym hours and services at any time. All members must maintain an active membership for access to the gym and fitness classes. All applicants are to present a current photo ID (for example, driver's license or passport) to be eligible for joining and/or renewing memberships.
- The 10-visit memberships must be used within 12 months of purchase of date.
- Concession memberships require current proof of concession card, as per concession definition on the Juanita Nielsen Community Centre webpage.
- Gym members must be 16 years of age and over to access the gym.
- The Juanita Nielsen Centre gym may at times be unsupervised. Centre staff are on hand for general assistance.
- Personal trainers are prohibited to bring clients and generate income and coach members.
Timestops

Membership Freezes (Timestops) allow you to pause your active membership for 2 weeks up to 2 months on a membership, provided at least 2 weeks remain before its expiration. Each membership can request one timestop, covering holidays, travel, business, or medical reasons. Timestops must be requested in writing to jncc@cityofsydney.nsw.gov.au before taking leave. Note, we cannot backdate any timestop requests.

Your timestop request will be reviewed by management, and you will receive a written notification regarding its approval.

Refunds/membership termination
All requests must be made in writing to jncc@cityofsydney.nsw.gov.au. A termination fee of 30% of the total membership value, capped at $55 will be applied to all membership refund/cancellation requests. The refund balance will be paid out minus the termination fee on a pro rata basis of the remaining membership. The City of Sydney will provide refunds to your nominated bank account and can take up to 4 weeks to process. Your bank details will be required to perform the electronic funds transfer.

Release and indemnity
In consideration of the Juanita Nielsen Community Centre providing me with gym membership, which entitles me to engage in fitness activities at the centre, I:
1. Release and forever discharge the Juanita Nielsen Community Centre from all actions, suits, proceedings, claims, demands, losses damages, penalties, fines, costs and expenses however arising (except where caused by Juanita Nielsen Community Centre’s gross negligence) that I may have or may have had but for this release arising from or in connection with my involvement in fitness activities of the Juanita Nielsen Community Centre.
2. Indemnify Juanita Nielsen Community Centre to the extent permitted by law in respect of any actions, suits, proceedings, claims, demands, losses, damages, penalties, fines, costs and expenses, arising as a result of or in connection with my involvement in fitness/exercise activities of the Juanita Nielsen Community Centre. My liability to indemnify the Juanita Nielsen Community Centre will be reduced proportionally to the extent that any act or omission of the Juanita Nielsen Community Centre contributed to the loss or liability
Gym etiquette
1. A towel must be used and placed on all machines.
2. Appropriate clothing and fully enclosed shoes must be worn.
3. Membership cards must be scanned on gym entry.
4. All equipment must be put away after use.
5. Swearing and other inappropriate behaviour will not be tolerated.
6. Staff reserves the right to ask members or guests to leave if required.
7. No entry is permitted for anyone under the influence of drugs or alcohol.
Agreement*

I have read and understood the exercise advice, and health privacy protection notice. I have completed the pre exercise health form accurately and truthfully and agree to abide by all terms and conditions at all times as directed by Juanita Nielsen Community Centre employees.I assume with full knowledge the dangers of my participation in fitness activities and do so at my own risk.I believe that to the best of my knowledge, all of the information I have supplied within this form is correct.I acknowledge that Juanita Nielsen Community Centre gym may at times be an unsupervised fitness service.Photo ID and any seniors card and/or concession card may be requested to validate your membership and eligibility.
Date

DayMonthYear
Date
Privacy protection notice
Purpose of collection: This information is being collected for the purpose of participating in gym or fitness classes run by the Juanita Nielsen Community Centre.

Intended recipients: Social Programs & Services at the City of Sydney are the intended recipients.

Supply: The supply of this information is voluntary. If you are unwilling to provide this information, the City of Sydney may be unable to provide access to City of Sydney services.
Access/Correction: Please contact customer service on 02 9265 9333 or at council@cityofsydney.nsw.gov.au to access or correct your personal information.

Storage: The Social Programs & Services unit at the City of Sydney, located at 456 Kent Street, Sydney NSW 2000, is collecting this information and the City of Sydney will store it securely.

Other uses: The City of Sydney will use your personal information for the purpose for which it was collected and may use it as is necessary for the exercise of other functions.

For further details on how the City of Sydney manages personal information, please refer to our privacy management plan.
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Juanita Nielsen Gym

Your details

Terms and conditions

Privacy protection notice