Membership Application


 
Price Presenter
Membership Details
Additional Details
Par-Q
Payment Details

Complete the details below to create a new member profile

Personal Details

Please enter a valid email address.
Please enter a name
Please enter a surname
ID number field is required
Please select a date of birth in the format YYYY-MM-DD
Please enter a valid cellphone number
Next - Price Presenter

Membership Details

Please select a tariff
Next - Additional information

Additional information

Contract Number field is required
Parent / Legal Guardian Relationship field is required
Occupation field is required
Parent / Legal Guardian Name and Surname field is required
Emergency Contact Number field is required
Emergency Contact Email field is required
Postal Code field is required
Emergency Contact Name field is required
Emergency Contact Relationship field is required
Parent / Legal Guardian Email field is required
Postal Address field is required
Parent / Legal Guardian Contact Number field is required
Medical Aid No field is required
Medical Aid Company field is required
PAR-Q Notes field is required
Next - Par-Q

PARq

Are you a smoker? field is required
To the best of your knowledge are you fit to train? field is required
Are you currently taking any medication on a regular basis? field is required
Have your parents or siblings, prior to the age of 55 suffered any of the following: Heart Attack, Stroke, High Blood Pressure or High Cholesterol? field is required
Do you suffer from any of the following: High Blood Pressure, High Cholesterol or Diabetes? field is required
Do you have Medical Aid Cover? field is required
Do you drink alcohol more than three time a week? field is required
Do you currently engage in regular exercise? field is required
Are you currently pregnant? field is required
Are you currently experiencing high levels of stress? field is required

Next - Payment Details

Next - Membership Details

How will you be paying:

Bank Details

These debit details belong to:
Please enter the account holder Initials
Please enter the account holder surname
 
Please enter a valid branch code
Please enter a valid account number
 
Select a valid account type
Select a valid debit date
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