Gym Membership Application Form

GYM MEMBERSHIP APPLICATION FORM
Staying active is one of the recognised ways of maintaining your health. Committing to a regular gym program can really assist with this, but we know that it can be expensive. CFT will provide funding towards your annual gym membership.

Eligibility:
- Membership of CFT must be current;
- Available to all adults and children with CF.
Entitlement:
- $750 each year towards your gym membership.
- Members may only claim a total of $750 each year under this program and the Fitness Equipment program.
- We can reimburse you or pay the invoice directly. Whatever works best for you.
Process:

1. Complete this online form;

2. Let us know if you have paid the invoice, or you would like us to pay it. We will just need proof of purchase for the item and its specifications.

3. CFT will endeavour to process your application within 7-10 days (subject to staff availability).
Name of person requesting gym membership*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Email*

Confirmation Emailexample@example.com
Mobile Number*
Please let us know what you need from us: *
Please use this space if you ticked "other" above.
Details of person completing this form (if different from above)

Name

Street Address Line 2

Relationship

Mobile Number
DETAILS OF GYM*
Please upload a photo of any receipts if you have asked for a reimbursement.

Cancelof
BANK ACCOUNT DETAILS

Please provide the bank account details for any reimbursements.
BSB
Account Number
Bank account holder
Name
DECLARATION

I declare that all information I have provided to Cystic Fibrosis Tasmania is true and accurate. I understand if it is found that I have knowingly provided false or inaccurate information I may no longer be eligible to be a member, or receive any or all of the services and benefits provided by Cystic Fibrosis Tasmania.
E-Signature Name*
Date*

DayMonthYear
Date
Should be Empty:

GYM MEMBERSHIP APPLICATION FORM

Staying active is one of the recognised ways of maintaining your health. Committing to a regular gym program can really assist with this, but we know that it can be expensive. CFT will provide funding towards your annual gym membership.

BANK ACCOUNT DETAILS