Membership Application

Complete the details below to create a new member profile

Personal Details

Email: Please enter a valid email address.

Password:

Validate

Forgot Password

Your account has been validated, you may continue.

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

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

Physical Address:

Cell: Please enter a valid cellphone number

Gender: Please select a gender

Next - Price Presenter

Membership Details

Next - Additional information

Additional information

ID Number: ID Number field is required

Emergency Contact Name: Emergency Contact Name field is required

Emergency Contact Number: Emergency Contact Number field is required

Occupation: Occupation field is required

Contract Number: Contract Number field is required

Postal Address: Postal Address field is required

Emergency Contact Relationship: Emergency Contact Relationship field is required

Emergency Contact Email: Emergency Contact Email field is required

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

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

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

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

Postal Code: Postal Code field is required

PAR-Q Notes : (Please disclose any doubt about partaking in physical activities or health risks ): PAR-Q Notes : (Please disclose any doubt about partaking in physical activities or health risks ) field is required

Medical Aid No: Medical Aid No field is required

Medical Aid Company: Medical Aid Company field is required

Direct Marketing & Related Matters

I consent to @ Fitness retaining my information and contacting me for the purposes of direct marketing and related matters

Yes Please select marketing preference. No

Next - PAR-Q

PAR-Q

Single

1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?: 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

2. Do you feel pain in your chest when you perform physical activity?: Do you feel pain in your chest when you perform physical activity? field is required

3. In the past month, have you had chest pain when you were not performing any physical activity?: In the past month, have you had chest pain when you were not performing any physical activity? field is required

4. Do you lose your balance because of dizziness or do you ever lose consciousness?: Do you lose your balance because of dizziness or do you ever lose consciousness? field is required

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?: Do you have a bone or joint problem that could be made worse by a change in your physical activity? field is required

6. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?: Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? field is required

7. Do you know of any other reason why you should not engage in physical activity?: Do you know of any other reason why you should not engage in physical activity? 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 Date of Birth: Please enter the account holder date of birth

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

You will complete your credit card details after clicking submit

Bank details need to be checked, Check Now