The MD Fitness Center is nearly ready for members of the community to use! Click the link below to download the application, waiver form, and policies. After you have completed the application and waiver, return it with the membership fee to the JH/HS office at 214 S. Main St., Melcher-Dallas, IA, 50163 (or drop it off in person). Checks should be made out to Melcher-Dallas CSD. In a week or two, someone will contact you for a short tour of the facility, after which you will be able to begin using it.
Link for Application, Waiver and Policies
M-D Fitness Center
Registration, Informed Consent, and Release Agreement
All registration forms must be submitted yearly*
Member Information:
Name: __________________________________________________ Phone: ( )_______-____________
Address: ________________________________________________ City: ___________________
Email: __________________________________________________
Emergency Contacts:
Name: ____________________________________ Phone: ( )______-_________ OR( ) _____-_________
Name: ____________________________________ Phone: ( )______-_________ OR( ) _____-_________
Building Access: Your individual access will be granted with a card or through an app on your mobile device, and will serve to gain access to the facility through the northeast entrance. Access will be reprogrammed each July when your membership is renewed. The M-D Fitness Center has a video surveillance system with facial recognition, and your app access will alert the security system of your name and time of arrival. Do not let anyone else use your app access. We reserve the right to deny membership. Membership fees are non-refundable.
Select Membership Fee: Your membership fee is due now. Membership fees collected help defray the cost of upgrading the equipment and assist in paying for the maintenance of the room. All memberships are 1 year, August 1 -July 31. Membership costs will not be prorated if you join mid-year. All other areas of the facility are off-limits, including locker rooms, except for bathrooms located on the ground floor by the east doors and the fitness center.
___ $25.00: Resident Member(Members of the Melcher-Dallas community, families that reside in the school district, families of open-enrolled students, any alumni of Melcher-Dallas, any former employee that retired from this district.
___ $10.00: Resident Senior Citizen (55 and over)
___ $100.00: Non-Resident Member
___ $50.00: Non-Resident Senior Citizen (55 and over)
___ No Charge: All current employees of MDCSD, board members, and current students will not require a membership fee to use the M-D Fitness Center. Registration is required for each family member.
PARENT’S OR GUARDIAN’S ADDITIONAL INDEMNIFICATION
(Must be completed for participants under the age of 18 or for current students at MD)
MD students and children under the age of 18 may not participate in using the equipment at the M-D Fitness Center unless accompanied by a certified coach of Melcher-Dallas Community Schools or by a parent/guardian. This form is not required for students to use the facilities for a class during school.
An additional form is required
I have read the following rules and regulations regarding the M-D Fitness Center. By signing, I agree to the above terms as part of my membership. I acknowledge my membership may be suspended or revoked if violations occur regarding said membership.
Signature ___________________________________________________ Date __________________
For Office Use Only:
Access ID#: ________________________ | Paid by:
Cash Check __Credit Card | Identification Confirmed by:
_____________________________ |
M-D FITNESS CENTER WAIVER RELEASE
(PARTICIPANT AGREEMENT, RELEASE, AND ACKNOWLEDGEMENT OF RISK AND MEDICAL HISTORY)
A WAIVER FORM IS REQUIRED FOR EACH MEMBER
In consideration of the services of the Melcher-Dallas Community School District, their agents, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as the MDCSD), I hereby agree to release and discharge the MDCSD, on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate as follows:
1. I assume that the MDCSD equipment in the Fitness Center entails known and unanticipated risks, which could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.
The risks include, among other things: cardiovascular, (angina, hypertension, coronary artery disease, arrhythmia, cardiac arrest, heart attacks,) pulmonary system, musculoskeletal system (sprains, tears, breaks,) or any other health-related risk, known or unanticipated which could result in injury, death, illness, disease, emotional distress, or damage to myself, property, or third parties. Furthermore, I understand and acknowledge that we have no expertise in diagnosing, examining, or treating any medical condition.
2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
3. I warrant that I am in good health, and that I assume the risk and hold harmless MDCSD from any risk relating to any preexisting conditions I have.
4. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless the MDCSD from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of the MDCSD equipment or facilities, including any such claims which allege the negligent acts or omissions of the MDCSD.
5. Should the MDCSD or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
6. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.
Consult your physician before exercising at MDCSD. Follow the exercises carefully and exercise at your own pace. If you feel any strain, stop and consult your physician. By my signature below, I acknowledge that I have read the foregoing, understand it, and agree to the terms.
Print Name: ____________________________________ Phone: ___________________
Signature of Participant: _____________________________________ Date: __________________
PARENT’S OR GUARDIAN’S ADDITIONAL INDEMNIFICATION
(Must be completed for participants under the age of 18)
MD students and children under the age of 18 may not participate in using the equipment at the M-D Fitness Center unless accompanied by a certified coach of Melcher-Dallas Community Schools or by a parent/guardian. This form is not required for students to use the facilities for a class during school.*
Child’s Name: _______________________________ Grade: ______ In consideration of __________________________(print minor’s name), being permitted to use the equipment at the M-D Fitness Center. I further agree to indemnify and hold harmless the Melcher-Dallas School District from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation of Minor. |
Child’s Name: _______________________________ Grade: ______ In consideration of __________________________(print minor’s name), being permitted to use the equipment at the M-D Fitness Center. I further agree to indemnify and hold harmless the Melcher-Dallas School District from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation of Minor. |
Child’s Name: _______________________________ Grade: ______ In consideration of __________________________(print minor’s name), being permitted to use the equipment at the M-D Fitness Center. I further agree to indemnify and hold harmless the Melcher-Dallas School District from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation of Minor. |
Child’s Name: _______________________________ Grade: ______ In consideration of __________________________(print minor’s name), being permitted to use the equipment at the M-D Fitness Center. I further agree to indemnify and hold harmless the Melcher-Dallas School District from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation of Minor. |
Child’s Name: _______________________________ Grade: ______ In consideration of __________________________(print minor’s name), being permitted to use the equipment at the M-D Fitness Center. I further agree to indemnify and hold harmless the Melcher-Dallas School District from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation of Minor. |
Parent or Guardian Signature: _______________________________________ Date: ________________
Additional M-D Fitness Center Policies
Usage - As a member of the M-D Fitness Center, you may use the facilities during the hours of 4:00 a.m. to 7:30 a.m. and 5:00 p.m. to 11:00 p.m. Monday through Friday. On Saturday and Sunday, the M-D Fitness Center is available from 4 a.m. to 11:00 p.m. The facility will be utilized by students from 7:30 a.m. to 5:00 p.m., so please be respectful of these times. The M-D Fitness Center will not be available to members 7:30 a.m. to 5:00 p.m. Monday through Friday. During summer break, when school is not in session, hours will be from 4 a.m. to 11:00 p.m., 7 days a week.
In the event that the building is open for a school activity, members are still required to scan their card for access.
The M-D Fitness Center closes at 11:00 p.m. All members should vacate the building by this time. Cameras will monitor this activity and violations could result in loss of membership privileges.
Guest Policy - Guests are not allowed . Only members with a paid membership and access to the facility are allowed to use the facility. Non-members wishing to view the facility need to make an appointment with a staff member before entering.
Any member giving access to a non-member or expired member will automatically be charged a $20.00 security violation fee and will forfeit their membership.
Access - Your keycard or phone app will access the northeast doors of the JH/HS. Any attempts to enter other parts of the building will result in a breach and the silent alarm will be tripped. If this occurs you will lose your membership privileges. Do not allow anyone else (including family members) to use your access to the facility, or open the door to allow someone else in. Please make sure the door is completely closed when you enter/leave the facility.
Equipment Usage - When using free weights, be sure to use a spotter. Please return all free weights to racks when finished. Gym wipes are provided for cleaning pads and equipment when you are finished using it. During busy times, please limit your time on cardio equipment to 20 minutes.
Age Requirements - Persons under the age of 18, or who are a current student at Melcher-Dallas, are not permitted to use the M-D Fitness Center unless supervised by a member parent or certified staff member. Minors must be accompanied by THEIR parent. Minors will not be issued access to the facility.
Children under the age of 14 are not permitted to use the facility unless being supervised by a certified coach of Melcher-Dallas CSD.
Please make arrangements for children prior to using the M-D Fitness Center. Adequate space is not available for children to sit and watch.
Members violating this policy will be notified by management and could lose their membership privileges.
Safety and Security - The M-D Fitness Center and the surrounding premises are under 24-hour recorded video surveillance. This video system is used for security purposes only in the event of a crime. The surveillance does not protect you from harm in or on the building premises. You must use caution when entering or leaving the facility.
Severe Weather - In case of a tornado warning or high straight line winds, please go to the restrooms located by the northeast entrance. Do not attempt to leave the building until the all clear has been issued from the NWS. Do not stay in the open part of the building where you will be unprotected from possible broken glass.
Injury and First Aid - In the event that you or another individual becomes injured, you have several options:
-For minor injuries, (cuts, abrasions, etc.) a first aid kit is located on the north wall by the windows overlooking the gym
-There is an AED mounted to the wall by the windows overlooking the gym
-For serious injuries that need medical treatment, dial 911 from the courtesy phone
-Report all injuries (no matter how minor) to the school by calling and leaving a message at 641-947-3731.
Individuals with health problems should never exercise alone. For liability reasons and for your own security, do not admit ANY individual who does not possess a membership card, or those who have had their privileges suspended.
Lost or Stolen Items - The M-D Fitness Center nor the Melcher-Dallas CSD is not responsible for lost or stolen items. If you feel you have left something in error, please notify a faculty member and we will be happy to look for you.
Valuables are best left in your locked automobile or not brought to the facility at all.