Jefferson Recreation & Fitness Center Membership Application

Jefferson ID Barcode Number *This question is required.

Date: (example: 01/01/15) *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Campus Key *This question is required.

First Name *This question is required.

MI *This question is required.

Last Name *This question is required.

Department *This question is required.

Building/Floor/Room

Work Phone *This question is required.

Home Address *This question is required.

City *This question is required.

State *This question is required.

Zip *This question is required.

Home Phone (###) XXX-XXXX *This question is required.

Jefferson Email Address
If you do not have a Jefferson e-mail account you are not eligible for the payroll deduction
option. Please call 215-503-7743 with questions. *This question is required. This question requires a valid email address.

** Payroll deduction option is only available to full-time Jefferson employees. The total base
of the membership is $425.00. The membership fee will be deducted in equal bi-weekly
installments of $16.35 (for 26 pay cycles, one year) from your paycheck until it reaches the
goal amount. Please select one of the following options. If you opt to purchase a locker, a
Wellness Center staff memberwill contact you within one business day to provide your
locker number.

Membership Plans

Item	Fee	Total	Bi-Weekly Deduction
Base Membership	$425.00	$425.00	$16.35
Additions
Add Locker service	$425.00 + $65.00	$490.00	$18.85
Add Towel Service	$425.00 + $99.00	$524.00	$20.15
Add Both	$$425.00 + $65.00 + $99.00	$589.00	$22.65

Select A Membership Plan

What is your current locker number?

Locker Agreement

All lockers are the property of the Thomas Jefferson University. Lockers are to be used
for legitimate recreational purposes. Jefferson is not responsible for lost or stolen
articles from lockers, locker rooms and/or the fitness and recreation facilities.

Jefferson reserves the right to open a locker with or without the consent for cleaning,
maintenance or item removal for failure to renew.

Lockers not cleared out within seven (7) days of expiration will have contents removed
by facility staff. Items will be kept for 30 days, after which they will be discarded or
given to charity.

To reclaim items a $20.00 fee will be assessed.

All memberships are a commitment for one
year from the application date

Cancellation is possible only for separation from the university or affiliated institutions,
in which case a refund will be given for the unused portion of the membership. For
inability to utilize the facility due to a documented medical reason the membership will
be frozen until medical clearance is granted and a copy of it be provided to the
Jeff-IBC Wellness Center.

**Release from Liability Waiver**

I, the undersigned, do knowingly and voluntarily hereby release, waive, discharge and
covenant not to sue Thomas Jefferson University, its officers, employees, affiliates,
agents and students and hold all such entities/persons harmless from any and all
liability, claims, demands or suits, including negligence, involving personal injury,
accidents, illness (including death), or property loss arising from, but not limited to, my
voluntary use of the Jefferson-IBC Wellness Center located in Jefferson Alumni Hall
and/or participation in anyprogram(s) sponsored by the Office of Student Life and
Engagement. I accept fullresponsibility for all exercises that I undertake including the
use of weights, number of repetitions, and use of any and all machinery, apparatus
and equipment, not withstanding any consultation on exercise programs that I may
receive from the Office of Student Life and Engagement employees.

I acknowledge that I have read and understand the Release from Liability
Waiver, Payroll Deduction Procedure and Cancellation Policy. *This question is required.

Clear

Signature of