PARTICIPANT DECLARATION. Any election I have made on this form revokes all prior elections with regard to this form. I am familiar with the provisions of the Plan and agree to participate in the Plan subject to all of its provisions and subject to the Additional Terms and Conditions of Participation set forth in the Addendum to this Subscription Agreement. I understand that the Board of Directors of the Company reserves the right to terminate the Plan or to amend the Plan and my right to purchase stock under the Plan to the extent provided by the Plan or the Addendum. I understand that the effectiveness of this Subscription Agreement is dependent upon my eligibility to participate in the Plan. Date: Signature of Participant NAME (Please print): (Last) (First) (Middle) I elect to withdraw from the xxxxxxxxxx.xxx, inc. 2004 Employee Stock Purchase Plan (the “Plan”) and the Offering which began on (date) ____________________ and in which I am participating (the “Current Offering”). I understand that I am terminating immediately my interest in the Plan and the Current Offering, and that no further Contributions will be made (provided I have given sufficient notice before the next pay day). My Contributions not previously used to purchase shares will not be used to purchase shares in the Current Offering, but instead will be paid to me as soon as practicable. I understand that I will not participate in the Plan unless I elect to become a participant in another Offering by filing a new Subscription Agreement with the Company. I understand that I will receive no interest on the amounts paid to me from my Plan account, and that I may not apply such amounts to any other Offering under the Plan or any other employee stock purchase plan of the Company. Date: Signature: These Additional Terms and Conditions of Participation, including Appendix I attached hereto, constitute an addendum to the Subscription Agreement to the xxxxxxxxxx.xxx, inc. 2004 Employee Stock Purchase Plan (collectively, the Subscription Agreement and this Addendum are referred to herein as the “Agreement”). The terms of the Agreement are incorporated into the xxxxxxxxxx.xxx, inc. 2004 Employee Stock Purchase Plan, including any applicable subplans thereto (the “Plan”), and govern the terms of participation for participating employees (each, a “Participant”) in the Plan. Capitalized terms used but not otherwise defined herein shall have the meanings given to them in the Plan.
PARTICIPANT DECLARATION. If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form. I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and be-comes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. NAME DATE SIGNATURE Participant Signature: WITNESS Club Representative Signature: SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER Participant's Parent or Guardian Signature: ⯃ If you answered YES to one or more of the questions above, 🛆 Delay becoming more active if: ✓ You have a temporary illness such as a cold or fever; it is best to wait until you feel better. ✓ You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARmed-X+ at www. xxxxxxxxx.xxx before becoming more physically active. ✓ Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a qualified exercise professional before continuing with any physical activity program. Tanning Release & Informed Consent Member Name: DOB: Date: Address: City: Province: P. Code: Home Phone: Cell Phone: Email:
PARTICIPANT DECLARATION. Any election I have made on this form revokes all prior elections with regard to this form.
