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

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

BHPC Par-Q


Do you currently smoke? field is required
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? field is required
Are you or have you been pregnant in the last 6 months? field is required
Is your doctor currently prescribing medication for your blood pressure or heart condition? field is required
Is there any history of Coronary Heart Disease in your family? field is required
Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity? field is required
Do you know of any other reason why you should not do physical activity? field is required
Do you lose balance because of dizziness or do you ever lose consciousness? field is required
Do you have Diabetes Mellitus or any other metabolic disease? field is required
Do you feel pain in your chest when you do 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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