Membership Application



 

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 select a date of birth in the format YYYY-MM-DD
Please enter a valid cellphone number
Please select a gender

Membership Details


Additional information

ID Number field is required
Emergency Contact Name field is required
Emergency Contact Number field is required
Occupation field is required
Contract Number field is required
Postal Address field is required
Emergency Contact Relationship field is required
Emergency Contact Email field is required
Parent / Legal Guardian Name and Surname field is required
Parent / Legal Guardian Relationship field is required
Parent / Legal Guardian Contact Number field is required
Parent / Legal Guardian Email field is required
Postal Code field is required
PAR-Q Notes : (Please disclose any doubt about partaking in physical activities or health risks ) field is required
Medical Aid No field is required
Medical Aid Company field is required

Direct Marketing & Related Matters

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

Please select marketing preference.

PAR-Q


Medical Readiness Questionnaire


Has your doctor every said you have low/high blood pressure? field is required
Has your doctor every said you have any heart trouble? field is required
Is there any other good physical reason not mentioned here why you should not follow an activity program even if you wanted to? field is required
Have you ever injured your shoulder or knee or had surgery? field is required
Have you ever injured your back or do you have back pain? field is required
Do you have diabetes/asthma or any other condition? 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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