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 Arkin retaining my information and contacting me for the purposes of direct marketing and related matters

Please select marketing preference.

PAR-Q


Cardio Vascular Disease


Has your doctor ever consulted you on a possible heart condition? field is required
Has your doctor ever advised you not to do any physical activity before returning to consultation for recommendation? field is required
Have you ever, or do you feel any pain in your chest when you do physical activity? field is required
Have you had any chest pain or experiences of 'pins and needles' in your left arm in the last month when you are NOT doing any physical activity? field is required
Is your doctor currently prescribing any medical drugs (for example; water pills) for your blood pressure or heart condition? field is required

Musculo Skeletal Issues


Do you experience any pain in your joints, bones, or ligaments when changing your regular physical activity? field is required
Have you had any surgical intervention for any joint, bone, or ligament injury or condition? field is required
Has your doctor prescribed medication for bone and joint conditions that you may have? field is required

Respiratory Disease


Have you ever had trouble breathing when doing any regular physical activity? field is required
Are you currently under any medication for respiratory diseases or illnesses (for example; Asthma, Chronic Bronchitis, Emphysema, etc.)? field is required
Do you know of any other reason why you should not do physical activity? 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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