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

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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

Email: 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 Pulse Fitness Studio 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

Contraindications: EMS training will only be permitted for the following conditions after obtaining medical approval;

1. Pacemaker or other electrical implants?: Pacemaker or other electrical implants? field is required

2. Pregnancy?: Pregnancy? field is required

3. Circulatory disorder, acute stroke, stent, thrombosis and cardiovascular disease e.g. arteriosclerosis?: Circulatory disorder, acute stroke, stent, thrombosis and cardiovascular disease e.g. arteriosclerosis? field is required

4. Acute Illness: Fever, acute bacterial or viral infections, acute inflammatory processes (e.g. arthritis, inflammatory back pain)?: Acute Illness: Fever, acute bacterial or viral infections, acute inflammatory processes (e.g. arthritis, inflammatory back pain)? field is required

5. Malign tumors and or cancer?: Malign tumors and or cancer? field is required

6. Bleeding, bleeding tendency, hemophilia?: Bleeding, bleeding tendency, hemophilia? field is required

7. Diabetes mellitus?: Diabetes mellitus? field is required

8. Abdominal wall hernia or inguinal hernia?: Abdominal wall hernia or inguinal hernia? field is required

9. Severe neurological disorders (e.g. epilepsy, multiple sclerosis, amyotrophic lateral sclerosis etc.)?: Severe neurological disorders (e.g. epilepsy, multiple sclerosis, amyotrophic lateral sclerosis etc.)? field is required

10. Acute operation (within 8 weeks)?: Acute operation (within 8 weeks)? field is required

Next - Payment Details

Contract Duration:

Access Level:

Payment Method:

Next - Membership Details

How will you be paying:

Debit Order

EFT / Cash

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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