Membership Application

Complete the details below to create a new member profile

Personal Details

Email: Please enter a valid email address.

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

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 Burgundy HPC 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

BHPC Par-Q

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. Do you currently smoke?: Do you currently smoke? field is required

8. Do you have Diabetes Mellitus or any other metabolic disease?: Do you have Diabetes Mellitus or any other metabolic disease? field is required

9. 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

10. 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

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

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