Membership Form



 

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
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

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
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

Single


Do you feel pain in your chest when you perform physical activity? field is required
Do you know of any other reason why you should not engage in physical activity? field is required
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? field is required
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? field is required
Do you have a bone or joint problem that could be made worse by a change in your physical activity? field is required
Do you lose your balance because of dizziness or do you ever lose consciousness? field is required
In the past month, have you had chest pain when you were not performing any physical activity? 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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