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Applicant

Applicant Name

Full Name

Address 1

Address 2

City

State

Zip Code

Occupation

Date of Birth

Employer

Telephone Number

Email address

Vehicle Make/Model/Plate (please list all):

Co-Applicant

Co-Applicant Name

Relationship to Applicant

Address

Occupation

Employer

Telephone Number

Email Address

If any children are included (ages 12-20), kindly provide us with their names and dates of birth:

How did you learn of Belden Membership?

Another Member
I frequent Belden
Marketing

Please upload a photo for each person associated with the membership

Application & Credit Card Authorization

In submitting this application for Membership, I agree to abide by and be bound to the rules and standards of Belden House. As the applicant, I acknowledge that I am solely responsible for all house charges, fees and other expenses which may be incurred on my behalf by the co-applicant or any minor children listed herein.

Members understand and acknowledge that, from time to time, your use of Belden House may be restricted in whole or in part. Members will receive advance notice from members@beldenhouse.com through our periodic member newsletter. The newsletter will include, in addition, programming updates and news.

Once accepted, you will be contacted by Belden House to provide your credit card details securely over the phone. Your full annual membership fee and one-time initiation fee of $150 is payable upon receipt and will be charged to your credit card. All charges are subject to applicable sales taxes.

Should you have any questions whilst completing your application, please submit them to members@beldenhouse.com to receive a prompt response.

I agree to the rules, standards and terms above.

Please type your name to agree to the credit card authorization.

Date:

Name on Credit Card

Billing Address

Address 2

City

State

Zip Code

Release and Waiver of Liability

Use of swimming pool and Belden bathhouse: In the interest of your safety, we require you to follow the rules outlined herein. In addition, please read the safety rules that are posted throughout Belden House. If you have any questions, we will be happy to discuss them with you.

With regard to use of swimming pool and Belden bathhouse, Members agree that this Release and Waiver of Liability (“Release”) is governed by, and intended to be as broad and inclusive as permitted by the laws of the State of Connecticut. By signing this Release, Members are acknowledging that Member & Member Family is physically and mentally able to swim and engage in regular forms of exercise, that Member presents no physical risks of infectious diseases to the owners, employees and guests of Belden House and that the Member & Member Family is fully familiar with swimming and engaging in regular forms of exercise and the inherent risks involved with the aforementioned activities. Member expressly assumes all risk of loss, damage, illness or injury as a result of participating in usage of and/or swimming, including the risk due to Belden House. Members agree to fully release and discharge Belden House for any damages, illness, injuries or claims, including, but not limited to, self or any other person or property, as a result of Member & Member Family usage of and/or swimming, etc. Members fully understand and agree to release Belden House for its negligence in causing in whole or in part any illness or injury to any other guest, member, licensee, invitee, employee, etc. of Belden House.

Any equipment utilized from Belden House is due back according to the following schedule: Yoga Mats following the conclusion of wellness classes. Members assume full responsibility for the rented equipment and any other equipment that is included in such rental. Members agree to compensate Belden House at the full retail value, for damages and/or theft of equipment during the rental period. Belden House is not responsible for guests, who incur equipment malfunction (i.e. ripped mat, etc.) during the period they are using the equipment. Upon request and when possible, Belden House will replace any damages equipment with diﬀerent, but similar, equipment. Belden House will do its best to resolve any malfunctions, but this service is not guaranteed.

Member freely and voluntarily assumes the risks of using the equipment and/or participating in any scheduled tour, class, session, etc. Each Member acknowledges that he/she has executed this Release in order to use the equipment and/or participate in a scheduled tour, class, session, etc. For each Member, who is a minor, the adult Member signing on his/her behalf represents and warrants to Belden House that he/she is the legal guardian of that minor and possesses full legal authority to release and waive claims and to covenant not to sue Belden House on that minor’s behalf. By signing this Release, the Member is acknowledging that, the Member is at least eighteen (18)years of age. By signing this Release on behalf of a minor, the Member is agreeing that Member is the minor’s parent or legal guardian and the Member releases Belden House from any claims, lawsuits or responsibilities for that minor. Each of the undersigned has read this Release.

With regard specifically to the usage of the swimming pool, the Member acknowledges the following: (a) a minimum of two (2) adults, eighteen (18) years of age and older, must be present whenever the swimming pool is in use and at least one (1) of these adults must be on the pool deck and NOT in the water; (b) children under the age of eighteen (18) must be accompanied to the swimming pool by either a parent or a guardian, or an adult, who is responsible for the child and the child’s behavior; and (c) do not drink alcohol and swim. There is no lifeguard on duty.

With regard specifically to the usage of Belden bathhouse, usage is restricted to Members who are eighteen (18) years old and above. In addition, the cancellation policy is as follows: if a wellness treatment is canceled within seven (7) days a twenty-five percent (25%) refund will be provided; if a wellness treatment is canceled within forty-eight (48) hours no refund will be provided. No Member is permitted to use Belden bathhouse during the unstaﬀed hours of operation.

In an emergency, notify the operator immediately. A free telephone is provided at the pool. T elephone number for emergency services is 911.

Facilities can only be used during posted hours of operation.

I agree to the terms above on behalf of Self and all those Members listed on this application.