Online Member Application

This is a secure form, and the information will only be used to process your Berkshire South membership. Please allow 2-3 days for processing. Thank you!

Instructions: Please enter all the information requested below, type your name where indicated for signature, read the terms and conditions / cancellation policies, and click on the "Submit" button at the bottom to send your application. On-line applications are subject to verification.

Section I — Personal Information:

 
 
 

APPLYING FOR

(If checked, please skip to Section II unless contact info has changed)
 
Gender:  
 
 
 
 
 
        (optional)
    

Section II — Membership Agreement:

ABOVE-NAMED MEMBER HEREBY PURCHASES A MEMBERSHIP TO BERKSHIRE SOUTH REGIONAL COMMUNITY CENTER AND SIGNIFIES WITH HIS/HER INITIALS HERE AND SIGNATURE AT THE BOTTOM OF THIS FORM TO THE TERMS AND CONDITIONS AS SET FORTH IN THIS AGREEMENT.

    

MEMBERSHIP CATEGORY (Please check one)
INDIVIDUALS:       
FAMILIES:   
Additional Family Members Included in Single Parent / Two Parent / Couple Memberships:
      Gender:   
      Gender:   
      Gender:   
      Gender:   
TERM (Please check one)
          
    
 $
 $

 $
    
     
    

Section III — Membership Rollover / Electronic Funds Transfers (EFT):

Please note: EFT may be used on annual and 6-month membership terms only.

This Agreement authorizes the Center to bill your credit card or bank account (as specified below) for each remaining month following the first month through the term of the agreement for your dues. Members who decide not to renew this Agreement at the end of the term shall so advise the Community Center in writing at least thirty (30) days prior to the end of that period. Failure to notify the Center in a timely manner will result in automatic renewal of your membership. Members paying through electronic funds transfer are required to provide the Community Center with thirty (30) days advance notice of cancellation or termination of this contract.

As indicated above in Section II, Deposit/First Month's Dues Received on Account, an accompanies this Membership Agreement by credit card payment.

EFT Contribution:
    
 $
     
 
    
 
 
    

Section IV — Informed Consent for Exercise Participation / Physical Activity Readiness:

I desire to engage voluntarily in the Berkshire South Regional Community Center exercise and fitness program in order to improve my physical fitness. I understand that the activities are designed to place a gradually increasing workload on the cardio-respiratory system and to thereby improve its functions. The reaction of the cardio-respiratory system to such activities cannot be predicted with complete accuracy. There is an increased risk of stroke or heart attack and joint injuries during exercise. I understand that I am responsible for monitoring my own condition throughout the exercise program and should any unusual symptoms occur such as dizziness, loss of coordination, light-headedness, nausea or shortness of breath, I will cease my participation and inform a staff person of the symptoms.

In signing this form, I affirm that I have read this form in its entirety and understand the nature of an exercise program. I also affirm that my questions regarding exercise have been answered to my satisfaction. In the event a medical clearance is suggested due to my answers provided in this section, I understand it is my responsibility to obtain said clearance from my health care provider.

Also in consideration for being allowed to participate in the Berkshire South exercise program, I agree to assume the risk of such exercise and further agree to hold blameless Berkshire South and its staff members conducting any exercise program or instructions from any and all claims, losses, or related causes of action for damages, including, but not limited to, such claims that may result from my injury or death, accidental or otherwise, during or arising in any way from exercise.

Please answer every question listed below. Complete honesty is expected in all answers. If you answer "Yes" to any of the questions, you will be required to provide Berkshire South with a doctor’s written permission clearance for exercise.

  1. Has your doctor ever said you have a heart condition and recommended only medically supervised physical act?
      
  2. Do you have chest pain brought on by physical activity?
      
  3. Have you developed chest pain at rest within the past month?
      
  4. Do you tend to lose consciousness or lose your balance as a result of dizziness?
      
  5. Do you have a bone or joint problem that could be aggravated by physical activity?
      
  6. Is your doctor currently prescribing medication for your blood pressure or heart condition?
      
  7. Are you aware, through your own experience or a doctor’s advice, of any physical reason against your exercising without a doctor’s approval?
      

Section V — Terms and Conditions / Cancellation Policies:

ALL MEMBERSHIPS ARE NON-REFUNDABLE AND NON-TRANSFERABLE

MEMBER CONTACT INFORMATION: The member’s contact information, including address, telephone number, and e-mail address shall be as set forth on the front of this Agreement or at such other as the Member shall advise the Community Center in writing.
MEMBER RESPONSIBILITIES: Member is aware that Berkshire South Regional Community Center is an intergenerational facility open to a diverse population and will act respectfully toward all other members and guests. Member acknowledges that inappropriate actions by himself, his family, or his guests could result in termination of his membership. Further, Management of the Center may suspend or cancel the rights, privileges, or memberships of any Member whose actions are detrimental to the enjoyment of the Center facilities by other members, or for failure to comply with Center rules. Center Management may from time to time change the rules governing the operation of the Center, schedules of activities and hours of operation. Notice of these changes will be made available to Members through normal means of communication. Member assumes responsibility of checking individual areas of the Center for posted changes pertaining to his/her interests. Member is aware that any exercise program undertaken may create physical stress resulting in harmful effects. It is solely Member’s responsibility to consult with a physician prior to commencing any exercise program (especially if there are any present or potential problems or Member is a male over age 39 or a female over age 49), to remain under medical supervision if that is indicated, to seek medical assistance in the event of injury, and to inform Berkshire South of any adverse changes in his medical condition. Member recognizes that the use of exercise equipment and other facilities provided by Berkshire South carries some risk of accidental injury to himself and others and agrees to use such equipment and facilities with due care.
LIABILITY WAIVER: The Center shall not be responsible or liable by any member or guest for loss of property for any reason. Member acknowledges that there is risk involved in leaving personal property either unattended or in an unlocked locker.
INSUFFICIENT FUNDS: All checks and monthly payment plans that are returned with insufficient funds are subject to a $20.00 fee.
ARREARS AND DEFAULT: Any unpaid balance beyond 60 days will result in membership termination as per terms of Default to follow. Default in the payment of fees or installments of fees when due or default or other breach of terms may result in termination by the Community Center of this Agreement and membership. In such an event, the Member is required to pay the unpaid balance of dues under this contract, all Center charges and costs of collections, including reasonable attorney’s fees.
RENEWAL OPTION: If a Member decides not to renew this Agreement at the end of the term, the Member shall so advise the Community Center in writing at least thirty (30) days prior to the end of that period.
LOST KEY TAGS: Membership key tags will be replaced free of charge once following initiation of membership. Key tags will be replaced at a cost to the member of $5.00 thereafter.
FREEZE REQUESTS: During the course of your 12-month membership, Berkshire South may freeze your membership following receipt of a Freeze Request and appropriate documentation for a period of up to three months for the following reasons only: serious illness; injury or surgery; death in the family or family crisis; return to school (college or high school); dual residency (of one month or more). This freeze does not impact monthly billing. Monthly billing for the frozen membership will proceed with the original payment schedule. Only one year memberships may be frozen. No freezes will be considered retroactively.
CENTER EQUIPMENT, FACILITIES AND HOURS: No refund whatsoever will be given for equipment or facilities temporarily out of order. Community Center hours are subject to change based on seasonal demands and the Center may be closed for certain holidays, maintenance, repairs, emergencies, staff training, and the like. Members will have no claim against the Center for extending or providing additional credit for periods closed.
CONSUMER’S RIGHT TO CANCELLATION: This contract may be canceled without penalty or further obligation by completing and returning a Membership Cancellation Form within three (3) business days of the date of this contract to Berkshire South Regional Community Center. The Cancellation Form may be attained in person at the Front Desk of Berkshire South or by calling 413-528-2810.
ADDITIONAL RIGHTS TO CANCELLATION: You or your estate may also cancel this contract for any of the following reasons: If upon a doctor’s order you cannot physically or medically receive the services because of significant physical or medical disability for a period in excess of 3 months; in case of your death; if the health club services to be provided under this contract are not available because the seller fails to open a planned health club or location, or substantially changes the operation of a health club or location; if you move either your residence or your place of employment more than 25 miles away from any health club operated by the seller or a substantially similar health club which will accept the seller’s obligation under the contract. Cancellation requests must be received in writing and delivered and postmarked by certified or registered mail to Berkshire South Regional Community Center at least thirty (30) days prior to desired date of cancellation. Return of any fees and dues paid is contingent upon full settlement of any outstanding charges. Members paying through electronic funds transfer are required to provide the Community Center with thirty (30) days advance notice of cancellation or termination of this contract. Failure to provide appropriate notice will result in an additional month’s dues being deducted from the account of record.

I have read the terms and conditions on the front and reverse sides of this application and with my signature indicate my agreement to the terms contained herein.