Membership Application



 

Complete the details below to create a new member profile

Personal Details

Please enter a valid id/passport number
Please enter a name
Please enter a surname
Please select a date of birth in the format YYYY-MM-DD
Please enter a valid cellphone number

Membership Details


Additional information

Postal Code field is required
Emergency Contact Name field is required
Emergency Contact Relationship field is required
Parent / Legal Guardian Email field is required
ID number field is required
Postal Address field is required
Parent / Legal Guardian Contact Number field is required
Medical Aid Company field is required
Contract Number field is required
Parent / Legal Guardian Relationship field is required
Medical Aid No field is required
Occupation field is required
Parent / Legal Guardian Name and Surname field is required
PAR-Q Notes field is required
Emergency Contact Number field is required
Emergency Contact Email field is required

Direct Marketing & Related Matters

I consent to Ufitt Life (Pty) Ltd retaining my information and contacting me for the purposes of direct marketing and related matters

Please select marketing preference.

PAR-Q


Medical Questions


Do you ever have pain in your chest or heart? field is required
Do you suffer from frequent cramps in legs? field is required
Has a doctor ever said your blood pressure was too high? field is required
Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary? field is required
Do you know of any reason why you should not be involved in any physical activity? field is required
Do you suffer from swollen ankles or joints? field is required
Are you on any chronic medication? field is required
Do you ever notice extra heartbeats or skipped beats? field is required
Do you suffer from any chronic or acute illnesses? field is required
Does your heart often race? field is required
Do you often have difficulty breathing? 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
×