Barton

Harm's Wellness Center Faculty/Staff Membership Form

July 1, 2018 - June 30, 2019

Date:

Name:

Email Address:

Home Address:

Home Telephone #:

Cell #:

College Position:

Department/Division:

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


Electronic Signature:
 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.

*Required

Once approved, payment is to be made with Barton's business office. Thank You.

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