Membership Application

Complete the details below to create a new member profile

Personal Details

ID number: Please enter a valid id/passport number

Password:

Validate

Forgot Password

Your account has been validated, you may continue.

Name: Please enter a name

Surname: Please enter a surname

Email: ID Number field is required

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

Search Address via Google:

Street address

Street Name

Suburb

City

Postal Code

Country

Cell: Please enter a valid cellphone number

Gender: Please select a gender

Next - Price Presenter

Membership Details

Next - Additional information

Additional information

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 Reboot Health and Fitness 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

Medical/Physical Readiness Questionnaire

1. Has your doctor ever confirmed that you have a heart condition?: Has your doctor ever confirmed that you have a heart condition? field is required

2. Has your doctor ever recommended yu should only do physical activity as recommended by a doctor?: Has your doctor ever recommended yu should only do physical activity as recommended by a doctor? field is required

3. Do you feel any pain in your chest when you do physical activity?: Do you feel any pain in your chest when you do physical activity? field is required

4. In the past month, have you had any chest pain when you were not doing any physical activity?: In the past month, have you had any chest pain when you were not doing any physical activity? field is required

5. Do you lose your balance because of dizziness or do you ever lose consciousness?: Do you lose your balance because of dizziness or do you ever lose consciousness? field is required

6. Do you have any bone or joint problems that could be made worse by physical activity?: Do you have any bone or joint problems that could be made worse by physical activity? field is required

7. Is your doctor currently prescribing any medication for your blood pressure or any heart condition?: Is your doctor currently prescribing any medication for your blood pressure or any heart condition? field is required

8. Are you pregnant or have you been pregnant in the last 6months?: Are you pregnant or have you been pregnant in the last 6months? field is required

9. Are you diabetic?: Are you diabetic? field is required

10. Do you know of any reason why you should not do physical activity?: Do you know of any reason why you should not do physical activity? 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

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

Account Holder Email address: Please enter the Account Holder email address

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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