Registration Form

Full Name*

First NameLast Name

Email Address*

example@example.com

Phone Number*

Area CodePhone Number

Date of Birth*

Date

Gender

MaleFemaleOther

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Emergency Contact Name

First NameLast Name

Relationship

Emergency Contact Phone Number

Area CodePhone Number

Do you have any medical conditions or allergies?

YesNo

If yes, please provide details

Choose Membership Type*

IndividualFamily

Choose Membership term*

Preferred Start Date

Date

I, the undersigned, agree that the use of any of the Te Kauwhata Community Fitness Centre facilities is at my own risk; 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, family under 16 years old will always be accompanied by a legal guardian and that all family members under 16 will be my responsibility. By signing below, I agree to the above terms. I also understand that if I lose my key tag I will need to purchase another one, and if my membership lapses for longer than 14 days I will need to pay $15 to reactivate my tag.

Signature

Registration Form

Personal Information

Emergency Contact Information

Medical Information

Membership Information