DIRECT DEBIT
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (0000-000-000).
D.O.B
Email
example@example.com
Address
Street Address
Street Address Line 2
Suburb
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (0000-000-000).
Establishment Fee (once only payment)
$49
Session Option
One on One PT 12WK ($99)
Online Program (Tailored) ($44)
Train with a bestie ($66ea)
Group Personal Training x 3($90)
Group Personal Training x 2 ($70)
One on One PT Casual ($111)
WINTER SPECIAL PT 8WK ($50)
Debit Amount
Debit Arrangement
Please Select
Regular
Once only
Debit Frequency
Please Select
Weekly
Fortnightly
Monthly
Upfront Full payment
Start Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Minimum Term
Please Select
12 Weeks
8 Weeks (Winter Special)
Financial Institution
Account Holder Name
BSB
Account Number
Signature
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Save
Submit
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