Membership Form

Complete the details below to create a new member profile

Personal Details

ID number: Please enter a valid id/passport number

Password:

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Name: Please enter a name

Surname: Please enter a surname

Date of Birth: Please select a date of birth in the format YYYY-MM-DD

Physical Address:

Cell: Please enter a valid cellphone number

Gender:

Next - Membership Details

Membership Details

Tariff: Please select a tariff

Next - Additional information

Additional information

Emergency Contact Name: Emergency Contact Name field is required

Emergency Contact Relationship: Emergency Contact Relationship field is required

Parent / Legal Guardian Email: Parent / Legal Guardian Email field is required

Email: ID number field is required

Postal Address: Postal Address field is required

Parent / Legal Guardian Contact Number: Parent / Legal Guardian Contact Number field is required

Medical Aid Company: Medical Aid Company field is required

Contract Number: Contract Number field is required

Parent / Legal Guardian Relationship: Parent / Legal Guardian Relationship field is required

Medical Aid No: Medical Aid No field is required

Occupation: Occupation field is required

Parent / Legal Guardian Name and Surname: Parent / Legal Guardian Name and Surname field is required

PAR-Q Notes: PAR-Q Notes field is required

Emergency Contact Number: Emergency Contact Number field is required

Emergency Contact Email: Emergency Contact Email field is required

Postal Code: Postal Code field is required

Next - Par-Q

Step1

Chest pain/discomfort with exertion : Chest pain/discomfort with exertion field is required

Burning/cramping sensations in your lower legs when walking short distance : Burning/cramping sensations in your lower legs when walking short distance field is required

Does your client experience: : Does your client experience: field is required

Unpleasant awareness of a forceful, rapid or irregular heart rate : Unpleasant awareness of a forceful, rapid or irregular heart rate field is required

Ankle swelling : Ankle swelling field is required

Dizziness, fainting, blackouts : Dizziness, fainting, blackouts field is required

Difficulty breathing : Difficulty breathing field is required

Step2

Have you been training for 30 min, at a moderate intensity at least 3 days per week, for the past 3 months. : Have you been training for 30 min, at a moderate intensity at least 3 days per week, for the past 3 months. field is required

Step3

hypertension : hypertension field is required

depression : depression field is required

pacemaker/implantable cardiac : pacemaker/implantable cardiac field is required

diabetes : diabetes field is required

metabolic syndrome : metabolic syndrome field is required

or coronary angioplasty : or coronary angioplasty field is required

congenital heart disease : congenital heart disease field is required

dyslipidaemia : dyslipidaemia field is required

heart surgery, cardiac catheterization, : heart surgery, cardiac catheterization, field is required

heart failure : heart failure field is required

lung disease : lung disease field is required

heart surgery, cardiac catheterization, : heart surgery, cardiac catheterization, field is required

heart valve disease : heart valve disease field is required

cancer : cancer field is required

kidney disease : kidney disease field is required

a heart attack : a heart attack field is required

defibrillator/rhythm disturbance : defibrillator/rhythm disturbance field is required

Next - Payment Details

How will you be paying:

Debit Order

Bank Details

These debit details belong to:

This member

Someone else

A Company

Company registration No: Please enter the account holder id number

Company Name: Please enter the account holder name

Company email address: Please enter the account holder email address

Valid Signatory ID no: Please enter the account holder id number

Valid Signatory Cell: Please enter the account holder cell number

Valid Signatory Initials: Please enter the account holder Initials

Valid Signatory Surname: Please enter the account holder surname

Bank:

Branch code: Please enter a valid branch code

Account number: Please enter a valid account number

Account type: Select a valid account type

Debit Date:Select a valid debit date

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