This is for evaluation purposes only. All information provided will be considered confidential and treated as such. Completing this form does not establish a relationship between WellQuest and the aforementioned facility. A WellQuest representative will contact you once this information is reviewed.

* Required Field

  DateNovember 20, 2008
* Completed by

 
GENERAL INFORMATION

* Club Name
* County
* Address
* City
* State   Zip 
* Phone
* Fax
Website? WWW.
* Owner's Name
* Manager's Name
* E-mail Address
Year Established

 

 

Is this facility registered/bonded with the state consumer affairs department?
Yes   No   Not required

 

 
MEMBERSHIP FEES

Monthly Dues:
Single $
Couple $
Family $
Corporate $
Senior $
Initiation fees:
Single $
Couple $
Family $
Corporate $
Senior $

 

Paid in Full:
Single $
Couple $
Family $
Corporate $
Senior $

 

 
HOURS OF OPERATION

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

 

 
FACILITIES/ EQUIPMENT (where applicable)
AerobicsAquatic Exercise
BasketballCardiovascular Equipment
Child CareGroup Cycling
Kick BoxingMassage
Nutritional Counseling  Personal Training
Physical TherapyPool - Indoor
Pool -OutdoorRacquetball
SaunaSquash
Steam RoomTennis-Indoor
Tennis -OutdoorTrack-Indoor
Track-OutdoorWhirlpool
YogaPro Shop
Co-EdWomen Only

 

 
EXERCISE PROGRAMING (where applicable)
Health History QuestionnairePar-Q
Physician's ConsentAge minimum
(if yes specify)
Is the fitness center floor always covered by an Instructor?
Yes  No

 

 


ADDITIONAL COMMENTS
   



 

 

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