Membership Form



 

Complete the details below to create a new member profile

Personal Details

Please enter a valid id/passport number
Please enter a name
Please enter a surname
Please select a date of birth in the format YYYY-MM-DD
Please enter a valid cellphone number

Membership Details

Please select a tariff

Additional information

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

General Health


Used inhaler medication or been troubled by shortness of breath? field is required
Do you know of any other circumstances regarding your health and fitness that may cause you to be unable to carry out any exercises? field is required
Are you pregnant? field is required
Have you ever suffered from mental illness, depression, anxiety or stress? field is required
Have you ever had asthma? field is required
Are you taking any prescription medication? field is required
Do you have a pacemaker or any other electronic medical device (s)? field is required
Have you ever had any injuries that have led you to see a medical practitioner? field is required
Are you currently receiving treatment for any health conditions? field is required
Have you ever experienced fits, seizures, convulsions, fainting or blackouts? field is required
Have you ever been told that you have high blood pressure? field is required
Have you ever had shin splits? field is required
Have you ever had epilepsy? field is required
Do you suffer from any chronic illness? field is required
Have you ever undergone any surgical operations? field is required
Do you have diabetes or raised blood sugar levels? field is required
Have you ever had heart disease, a heart murmur, irregular heartbeat or chest pains (angina)? field is required
Have you ever suffered from arthritis or any bone or joint problems? field is required

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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