Membership Form

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

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

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

ID number: 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

Emergency Contact Name: Emergency Contact Name field is required

Emergency Contact Relationship: Emergency Contact Relationship field is required

Next - Par-Q

BHPC Par-Q

Is there any history of Coronary Heart Disease in your family?: 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?: 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?: 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?: 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?: 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?: Do you feel pain in your chest when you do physical activity? field is required

Do you currently smoke?: 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?: 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?: 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?: Is your doctor currently prescribing medication for your blood pressure or heart condition? field is required

Next - Payment Details