Strength Tek Fitness Centre Carling Avenue, Ottawa, ON K8N 5B7

FITNESS CENTRE APPLICATION FORM Please complete the following information in full.

Current Date:

Application Status: New (first time member) Renewal (current membership up for renewal) Returning (held a membership in the past) Member Information

Employee ID #: Applicant Last Name: First Name: If not a campus employee please provide Employer: Campus employee/Nortel Pensioner name:

Work Phone: Home Phone: Work Email: Date of Birth (M/D/Y/): Gender: Male Female Emergency Contact Name: Relationship: Phone:

Membership Type: Please select one: (prices do no include tax)

Employer Fee (pre tax) Term Information Initial 12 month commitment period. After the initial 12 month period, the Campus Employee $240.00 12-month membership agreement automatically renews on a month-by-month basis. Employee Spouse Initial 12 month commitment period. After the initial 12 month period, the $240.00 12-month Nortel Pensioner/Spouse membership agreement automatically renews on a month-by-month basis.

Please Specify Please note: one payment required at start of membership (cash, debit, $ Other: ______cheque or credit card).

Optional Towel Service (membership add-on): (one payment at start of term; cash, cheque or credit card) 1 year $85 Other $ Please specify: ______

Payment Terms Confirmation:

PAD (from Bank Account): Monthly Pre Authorized Debit (Authorization Form must be completed and attached) Credit Card: payment must be for a 12 month period Card Type (select one): VISA Master Card

Please Note: All credit card payments are paid to Strength Tek - - this will be shown on the statement.

Card Number: Expiry Date: Signature:

Personal Cheque #: (payment must be for full term period. There will be an Admin fee of $20.00 for NSF Cheques)

Terms and Conditions I understand the following conditions of my membership: - I must be eligible for a membership and will respect the terms and condition of that membership. - As a new member, I will participate in a “New Member Orientation”. - I will respect the rules and regulations in the Fitness Centre and conduct myself in a safe and respectful manner. - The initial membership term is for 12 months. After the initial 12-month commitment period memberships paid by perpetual direct account withdrawals with renew automatically. - A Cancellation Request Form must be completed and submitted to cancel a membership. All Membership Cancellations are subject to approval and an administration fee may apply. During the 12-month commitment period my Cancellation Request will only be approved if: - I am no longer eligible to be a Fitness Centre Member (termination date for verification purposes is required). - I have a medical reason that prevents my participation beyond a 2-month period (physician’s note is required). - Once a cancellation has been approved, the last transaction for those paying by perpetual direct account withdrawals will take place the first Friday of month following cancellation approval. Individuals who paid their membership in full at the start of the membership term and are eligible for cancellation will be issued a pro-rated refund (a cancellation fee may apply). Fees collected for membership prior to cancellation approval are non- refundable. - It is my responsibility to notify the Fitness Centre of any changes to my banking information that may prevent payment of my membership fee. - It is my responsibility to notify the Fitness Centre if there is any change to my membership eligibility status, or if there are any medical conditions or any other situation that may impede my membership. Failure to notify staff will result in continued account withdrawals; these payments are non- refundable. - Failure to comply with the above Terms and Conditions may result in the immediate withdrawal of my membership privileges.

The information collected will be treated as confidential and is used for the administration of your fitness centre membership.

Date: Member Signature:

Office Use Only: Membership Fee: Towel Fee (optional): TOTAL PAYABLE: Payment Process Date: Processed by: Payment Method: PAD Cheque #______Cash $______Debit Credit Card Authorization #: Membership Process Date: Processed by: Membership #: Notes:

Page 1 of 2 Strength Tek Fitness Centre Carling Avenue, Ottawa, ON K8N 5B7

PAR-Q and YOU (A Questionnaire for People Aged 15 to 69) Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctors before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR - Q will tell you if you should check with your doctor before you start. If you are over 69 and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Yes No Please read the questions carefully and answer each one honestly: check YES or NO. 1. Has your doctor ever said that you have a heart condition and that you should do only physical activity recommended by a doctor? 2. Do you feel pain in your chest when you do physical activity? 3. In the past month, have you had chest pain when you were not doing physical activity? 4. Do you lose your balance because of dizziness or do you ever lose consciousness? 5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? 7. Do you know of any other reason that you should not do physical activity?

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR - Q and which questions you answered YES.  You may be able to do any activity you want - as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.  Find out which community programs are safe and helpful for you. If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:  Start becoming much more physically active-begin slowly and build up gradually. This is the safest and easiest way to go.  Take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active. Delay becoming much more active if: you are not feeling well because of a temporary illness such as a cold or a fever - wait until you feel better; or if you are or may be pregnant - talk to your doctor before you start becoming more active. Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan. INFORMED USE OF THE PAR - Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity. Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions. I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction.

Member’s Printed Name Member’s Signature Date

Participant Consent/Release I ______(name), acknowledge and agree that my participation in the Nortel Networks Fitness Centre, its fitness assessment programs and any other programs or activities such as, but not limited to, group exercise, is voluntary, at my own risk. I understand that should the Nortel Networks Fitness Centre I am joining or the activity that I am participating in be unsupervised, I must always exercise with another individual (Buddy System) and use a spotter when lifting free weights. I agree that I will not grant any person entry to the Nortel Networks Fitness Centre who is not a member of the Nortel Networks Fitness Centre. I agree that I will follow any applicable rules and not engage in any horseplay or other unsafe behavior in the Nortel Networks Fitness Centre or the program or activity in which I am participating. I understand and agree that Nortel Networks Corporation and its direct and indirect subsidiaries and affiliates (“Nortel Networks”), and any third parties which Nortel Networks engages to operate or supply all or any part of the Nortel Networks Fitness Centre and any of the officers, employees, agents, contractors, subsidiaries, affiliates, successors and assigns of the foregoing (“Releasees”) are not liable for any injury, illness, or death, which may result from my participation in the Nortel Networks Fitness Centre and its activities and programs. In consideration of my being permitted to participate in the Nortel Networks Fitness Centre and programs and activities contemplated herein and not withstanding whether any fitness personnel are or may be provided, I do for myself, my heirs, executors, administrators, successors and assigns, hereby RELEASE, WAIVE ANY RIGHTS THAT I MAY HAVE AND FOREVER DISCHARGE the Releasees OF AND FROM any and all actions, causes of actions, complaints, demands and claims or liabilities whatsoever in existence prior to on or after the date hereof whether in law or in equity, in respect of death, injury, loss or damage to my person or property HOWSOEVER CAUSED, arising or to arise by reason of my membership or participation in the Nortel Networks Fitness Centre, programs or activities contemplated herein to the extent permitted by applicable law; provided, however, that the foregoing release and waiver will not apply to benefits for which I may be eligible under the terms and conditions of any Nortel Networks benefits plans or programs in which I participate. I FURTHER UNDERTAKE TO HOLD AND SAVE HARMLESS AND AGREE TO INDEMNIFY all the Releasees from and against any or all liability incurred by any or all of them arising as a result of or in any way connected to my participation in the activities contemplated herein. I understand there are certain risks and perils inherent in any exercise activity and assume full responsibility for any inherent risk and danger. I hereby declare that I am in good physical health and that I am medically able to participate in and undertake the activities contemplated herein. I am not aware of any physical or mental disability, condition or disease that could be aggravated by the activities contemplated herein and/or could result in the deterioration of my health. I will inform the Nortel Networks Fitness Centre Staff should there be any change in my medical condition and understand this may require the completion of a form by my doctor, a fitness consultation and/or changes to or approval of my exercise program or activities to ensure continuing suitability. I agree that, ultimately, I alone am responsible for assessing whether my participation in the Nortel Networks Fitness Centre or any of its programs or activities poses any problem or hazard to me. To assist me in assessing this, I agree to complete a medical history questionnaire and any other required screening forms. If a physician’s approval is required, I agree to obtain it prior to participating or continuing to participate in the Nortel Networks Fitness Centre or any of its programs or activities and to exercise within any recommended restrictions.

Member’s Printed Name Member’s Signature Date

Page 2 of 2