Harm's Wellness Center Faculty/Staff Membership Form
July 1, 2018 - June 30, 2019
Home Telephone #:
Office Telephone #:
Please Check the one statment that applies.
This is a renewal
I have successfully completed one semester at Barton of either Physical Fitness I, Physical Fitness II, or Fundamentals of Physical Fitness.
I have been enrolled in a physical fitness program outside of Barton and am familiar with the proper manner of operation of the type of exercise equipment in the Harm's Wellness Center.
Please Briefly Explain
I certify that to the best of my knowledge the information on this form is true and complete without evasion or misrepresentation. I understand that if found to be otherwise, it is sufficient cause for rejection.*
By checking this box you have created an electronic signature as legally binding as your handwritten signature.
Once approved, payment is to be made with Barton's business office. Thank You.
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