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Membership Application

Personal Details

Price Presenter

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 - Price Presenter

Membership Details

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

PAR-Q

Medical Readiness Questionnaire

1. Are you Pregnant: Are you Pregnant field is required

Step1

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

3. 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

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

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

6. Ankle swelling : Ankle swelling field is required

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

8. Difficulty breathing : Difficulty breathing field is required

Step2

9. 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

10. hypertension : hypertension field is required

11. depression : depression field is required

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

13. diabetes : diabetes field is required

14. metabolic syndrome : metabolic syndrome field is required

15. or coronary angioplasty : or coronary angioplasty field is required

16. congenital heart disease : congenital heart disease field is required

17. dyslipidaemia : dyslipidaemia field is required

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

19. heart failure : heart failure field is required

20. lung disease : lung disease field is required

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

22. heart valve disease : heart valve disease field is required

23. cancer : cancer field is required

24. kidney disease : kidney disease field is required

25. a heart attack : a heart attack field is required

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

Next - Payment Details

Contract Duration:

Access Level:

Payment Method:

Next - Membership 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 company registration number

Company Name: Please enter the company name

Company email address: Please enter the company email address

Account Holder / Contact Person ID / Passport Number: Please enter the account holder id number

Account Holder / Contact Person Cell: Please enter the account holder cell number

Account Holder / Contact Person Initials: Please enter the account holder Initials

Account Holder / Contact Person Surname: Please enter the account holder surname

Bank:

Card Number: Please enter the correct credit card number.

Card Expiry Date: Please enter the card expiry date

Branch Code: Please enter a valid branch code

Bank Account Number: Please enter a valid account number

Account Type: Select a valid account type

Preferred Debit Date:Select a valid debit date

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