Membership Registration

Select your membership type*

Select payment frequency*

Full Name*

First NameLast Name

Email*

example@example.com

Please repeat your email*

example@example.com

Phone Number*

Area CodePhone Number

Date of birth *

Date

Ethnicity

This is for user statistics

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Emergency contact*

First NameLast Name

Emergency contact phone number *

Area Code Phone Number

Are you on any life saving medication, that may need to be administered in case of a medical emergency?*

YesNo

If yes please list your medications

Do you have any allergies; what are they and what action should be taken?*

YesNoNot Sure

If yes please state

What is your Gender?*

MaleFemaleOther

Do you have any disabilities?

If yes please state

Would you like to make an appointment to see a personal Trainer at an additional cost?

I, the undersigned, agree that the use of any of the Te Kauwhata Community Fitness Centre facilities is at my own risk. I have read and agree with the Terms of use and Fitness Protocols. Under the Health & Safety at work Act 2015; I take full responsibility for my own health & safety and will alert staff to any hazards or incidents & will follow procedures. I also understand that if this is a family membership, all names listed above will be my responsibility *if applicant is under 18 years of age
I also understand that if I do not return my key tag upon cancellation or expiry of my membership I will be charged a $25 lost key tag fee.
I, (name) blanks* agree to the above terms

Signature*

TK Fitness Registration