2025 Membership Registration Signing Up for our Wellness CenterAt Logan County Please fill out all the information down below: 2025 Member Registration Logan County Rehabilitation and Wellness Center Logan County Rehabilitation and Wellness Center 906 W 2nd Street, Oakley, KS 67748 785-672-8167 Name(Required) Full Name Birth Date Month Day Year Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell PhoneHome PhoneEmail Type of Membership Single Couple Family Pin Number (Pick a 4 digit # for the keypads)Please enter a number from 1000 to 9999.Couple and family memberships, please list all names and DOB to be included in the membership:Name Full Name RelationshipDate of Birth MM slash DD slash YYYY Name Full Name RelationshipDate of Birth MM slash DD slash YYYY Name Full Name RelationshipDate of Birth MM slash DD slash YYYY Name Full Name RelationshipDate of Birth MM slash DD slash YYYY Name Full Name RelationshipDate of Birth MM slash DD slash YYYY Acknowledgement I agreeI hereby register as a member of the Logan County Rehabilitation and Wellness Center. I acknowledge having received a copy of the Code of Conduct and I agree that I and the above listed members will abide by the same. Furthermore, I agree to pay all prevailing monthly dues so long as I or any of my other immediate family members retains membership. I understand my membership is nontransferable and dues are subject to change. I am aware and understand that I am responsible for monitoring my own condition through the exercise program and should any unusual symptoms occur, I will cease my participation and immediately inform the Wellness Center Staff or seek medical attention. All information obtained as a result of my utilization of this facility for participation in any programs shall be treated as privileged and confidential. This information may be used for billing, statistical or scientific purposes with my right of privacy mentioned. In consideration of the Logan County Rehabilitation and Wellness Center accepting this application, I release and discharge Logan County Rehabilitation and Wellness Center, it's employees, any and all persons connected with the facility from all rights, daims, demands and actions of any and every nature whatsoever for any and all loss, damage, injuries sustained by me or my Member Waiver(Required) I agree to the Member WaiverPLEASE READ CAREFULLY! THIS IS A LEGAL DOCUMENT, WHICH AFFECTS YOUR LEGAL RIGHTS! WAIVER AND RELEASE OF LIABILITY ASSUMPTION OF RISK AND INDEMNITY AGREEMENT In consideration of being permitted to use the Wellness Center facility, including all equipment, state and agree as follows on behalf of myself and my personal representatives, next of kin, heirs, executors, administrators, agents, and assigns: 1. I understand that any physical exercise or activity involves the risk of bodily injury, including permanent disability, paralysis, and death. I understand that such injury may be caused by my own actions or inactions, or the actions or inactions of others. 2. I agree to engage in any physical exercise or activity and to use the facility at my own risk. This includes, but is not limited to, the following: (a) my use of the parking area, sidewalk, equipment, and any other amenity in the facility; (b) my participation in any activity in the facility; and (c) use of any information, instruction, advice, example, direction, or suggestion I receive through any means while at the facility. I agree that I am voluntarily engaging in these activities and using the facilities, equipment, and amenities. I assume all risk of injury, illness, damage, or loss of any kind resulting from such activities and usage, including, but not limited to, any loss or theft of personal property. 3. I agree to release and discharge Logan County Hospital, (and its affiliates, employees, agents, representatives, successors, and assigns) to the fullest extent permitted by law, from any and all claims or causes of action (known or unknown) arising out of any negligence on the part of LCH. If, despite this agreement, I, or anyone on my behalf, makes a claim against LCH, I will indemnify, save, and hold harmless LCH from any litigation expense, attorney fees, loss, liability, damage, or cost LCH may incur as a result of such claim. I have read this agreement and fully understand its terms. I have had an opportunity to ask any questions I may have concerning this agreement, and all such questions have been answered to my satisfaction. I understand that this agreement cannot be modified orally. I understand that I have given up substantial rights by signing this agreement. I have signed this agreement freely and without any inducement or assurance of any nature. I intend this agreement to be a complete and unconditional release of all liability to the fullest extent allowed by law. I agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.Please type your full name to agree(Required) Full Name Today's Date(Required) MM slash DD slash YYYY Return to Our Service Page