St. Louis College of Pharmacy WellAware Fitness Center Application

Welcome St. Louis College of Pharmacy students and thank you for your interest in the BJC WellAware Center!

NOTE: If you are NOT a St. Louis College of Pharmacy student but you are interested in joining, please click here to complete our standard application.

By submitting this application, you are acknowledging and accepting that a non-refundable membership charge be applied to your account.

All College of Pharmacy student memberships will be valid from August 17, 2015 to August 16, 2016. No prorated membership rates will be offered.

*All non-dorm athletes please contact the athletics department to get a stamped paper application for submission*

First Name
Last Name
Student ID #:
What type of membership are you applying for?

Emergency Contact Information

Relationship to Applicant:
Phone Number:
Doctor's Name:
Doctor's Phone Number:

Physical Activity Readiness Questionnaire


Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Increasing physical activity is safe for most people. However, some people should check with their doctor before they start an exercise program.

If you are planning to become much more physically active than you are now, start by answering the questions below. If you are between the ages of 18 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.

Please read the questions carefully and answer each one honestly. Choose Yes or No.

1) Has a doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

2) Do you feel pain in your chest, dizzy, light-headed or similar feelings when you do physical activity?
3) In the past month, have you had chest pain, felt dizzy or light-headed or other similar feelings when you were not doing physical activity?
4) Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or a heart condition?
5) Do you have a bone or joint problem that could be made worse by a change in your physical activity?
6) Do you know of any other reason why you should not participate in any physical activity?
If you have answered Yes to one or more questions, the WellAware Center will contact your physician (contact information at the bottom of this form) for a release form after you sign up for membership.

Personal Health History

What percent of the time on the job do you sit? What percent of the time on the job do you stand? What percent of the time on the job do you lift heavy objects?

xx%, xx%, xx%

In your family history, has there been a heart attack or sudden death before the age of 60 years?
Do you currently have or have had a history of elevated blood pressure (>140/90 mmHg) and/or are you on hypersensitive medication?
Have you been told within the past 5 years that you have a history of elevated cholesterol levels (>200 LDL or <35 HDL)?
Are you diabetic?
Do you currently smoke/have you smoked in the last 5 years?
If you have answered Yes to two or more questions, the WellAware Center will contact your physician (contact information at the bottom of this form) for a release form after you sign up for membership. If you have answered No to all questions, continue with the fitness assessment to determine your basic fitness level (An exercise specialist will schedule this with you).

List of Medications

Name of medications and the reasons for taking:

Waiver of Liability


I desire to voluntarily exercise at the BJC WellAware Center. I acknowledge that my participation in exercise and the use of equipment is at my own risk and that the Center and its representatives shall not be liable for any claims, demands, injuries, damages, actions or causes of action whatsoever to my person or property arising out of or connected with the use of the Center's facilities.

I further understand that the course activities have been designed to gradually place an increasing workload upon my circulatory and muscular systems in an attempt to achieve improved function. The body's response to such activities cannot be predicted with complete accuracy; therefore, there is a risk of unexpected changes which can occur during or following the exercise session. These changes may occur in the form of, but not limited to, stress or damage to bones, joints, ligaments and/or muscles; or they may appear as abnormalities in blood pressure, heart rate or "cardiorespiratory function" and, possibly in some cases, heart attack or death.

I realize the chances of the above abnormalities occurring are decreased by compliance to a regular exercise program which adheres to the exercise rules and safety guidelines. I also realize that I am required to report promptly to my physician any signs or symptoms of distress, abnormality and/or pain.

I further acknowledge the existence and the need for Rules and Regulations including those governing the use of the Center's equipment and facilities and participation in programs and services. I hereby agree to comply with the Rules and Regulations and to amendments or additions to them as the Center decides are necessary.

I further consent to the administration of immediate medical care.

Finally, I attest that all of the previous information I have provided has been answered truthfully to the best of my ability.

Rights of Membership

I understand that my membership may be canceled if I am in violation of the Rules and Regulations of the BJC WellAware Center and I will not be entitled to any refund of the membership fee to the date of cancelation. I also understand that my membership does not confer upon me, or my spouse or children, any ownership interest in the Center or its property.


The BJC WellAware Center reserves the right to set and to change the rules and eligibility for membership of children under the age of 18.

Membership Policies


Guest Visits: Members may bring in a guest for up to four times per month. The guest must sign a liability form, follow all WellAware Center rules, and a pay a fee of $7.00 per visit.

Medical Circumstances: If a member is unable to exercise because of medical reasons, the regular membership may be put on hold. The member must have proof of a medical condition and inform WellAware Center management immediately. With the consent of the member, specific medical concerns will be forwarded to the member's physician. It is the responsibility of the member to follow their physician's guidelines.

Member Rules


1. Swiping membership card at reception desk is mandatory at arrival.

2. No one will be admitted without a current membership card. If you do not have your membership card, please notify a staff member to proceed with the check in process. If you have lost your card, replacement charge is $5.

3. Foul or abusive language will not be tolerated.

4. Abuse of any equipment or any part of the facility will result in immediate revocation of membership privileges.

5. No street shoes allowed on the aerobics floor.

6. No food or beverages permitted in the exercise area (water bottles permitted).

7. No persons under the age of 18 allowed in the Center.

8. Any lock or other equipment issued becomes the responsibility of the member. The member is liable for its return or subsequent charge.

9. Members acknowledge that the locker tooms are unattended, and any loss is the liability of the member.

10. Drink lots of water during your workout, even if you are not thirsty.

11. Proper attire is required. This includes soft-soled shoes and comfortable, breathable clothing. Tank tops are allowed, stomachs must be covered and never work out without a shirt. No scrubs of any type are allowed.

12. Avoid loose-fitting clothing that could be caught in the equipment.

13. Avoid wearing jewelry or watches.

14. Never use free weights where heavy weight is used without a spotter. Always use collars when using the Olympic bars.

15. Be courteous! Respect those working out around you.

16. Clean off the benches and equipment with provided disinfecting wipes after each usage.

17. Avoid loitering on equipment between exercises and sets.

18. Offer your help as a spotter to those in need. In this way you will feel comfortable asking others to help you.

19. If you notice problems with a piece of equipment, please advise the staff immediately. In this way we can all share in keeping the equipment functioning safely.

20. Conducting personal training or small group training is not allowed by non-BJC WellAware Center personnel.

This is my application for membership in the BJC WellAware Center. I understand that this application is subject to the review and approval of the Center. I am 18 years or older.

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