Membership Application General Information Name Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Phone Email GWID Membership Options Package General President's Club - Regular Size Locker President's Club - Full Size Locker **Visit the Campus Recreation website at (Membership Packages & Rates) for details on packages and rates. Authorization for Payroll Services Pay Frequency Bi Weekly Monthly I authorize the George Washington University Payroll Services Department or the George Washington University Hospital (UHS) to deduct my Lerner Health and Wellness Center membership fees from my paycheck on a bi-weekly/ monthly basis. These payroll deductions are perpetual and will continue until I complete a Membership Termination form. eSignature Date Date: Year Year20232024202520262027 Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date: Day Day12345678910111213141516171819202122232425262728293031 By using the e-signature feature of this online application, I represent and warrant without reservation that I have the legal right, power, and authority to agree to all terms contained in the electronic records of this online application on behalf of myself (or on behalf of the individual on whose behalf I am acting, if different). I further agree that my use of the e-signature feature of this online application constitutes an "electronic signature" as defined by the Electronic Signatures in Global and National Commerce Act ("E-Sign") and the Uniform Electronic Transactions Act ("UETA") and that I have formed, executed, entered into, accepted the terms of, and otherwise authenticated the terms specified herein for the use of the e-signature feature of this online application. Membership rates are subject to increase periodically. Waiver and Assumption of Risk In consideration of my acceptance into the Lerner Health and Wellness Center of The George Washington University, I, the undersigned, hereby for myself, my heirs, executors and administrators waive, release and forever discharge any and all rights and claims for damages which I may have or may hereafter accrue to me against The George Washington University, its trustees, officers, employees, faculty, students and its agents for any and all injuries suffered by me through my participation in said program. Further, I hereby indemnify, defend and save harmless The George Washington University, its trustees, officers, employees, faculty, students and its agents from any liability, damage, expense, causes of action, suits, claims or judgments arising from injury to person, including death, personal property including but not limited to theft, or otherwise which arises out of the act, failure to act, or negligence in connection with the participation in the activities which are the subject of this release. eSignature Date Date: Year Year20232024202520262027 Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date: Day Day12345678910111213141516171819202122232425262728293031 NOTE: All membership applications will be processed within 48-72 hours of receipt.