Member Registration Form

Title (Mr/Mrs/Miss/Md):

Gender: Male Female

Date of Birth:

Surname:

First Name:

Address:

Postcode:

Email:

Telephone (Home):

Telephone (Work):

Mobile:

Occupation:

Company:

Doctor's Name:

Doctor's Phone:

Emergency Contact:

Emergency Phone:

Do you have private health insurance? Y / N

If yes, which fund?

How did you find out about our Gym?

If you were referred, who by?

Which Membership are you signing up for:

Method of Payment: Quickpay Agreement Upfront Payment

Medical Questionnaire

Check any that apply:

Heart Disease Cardiovascular Condition Dizziness