Couples 12 Month Lock in - Application form

ParQ and Application Form

MOMENTUM FITNESS WARRNAMBOOL
Your membership with Momentum Fitness Warrnambool includes

- Fitness Program for each of your family members

- 1 x $65.00 Joining Fee including 24/7 Access Fobs

- Full access to Gymnasium

Once you have completed the form, please come in during staffed hours to collect your 24/7 access tags for each of your family members.

Please be aware that if you lose your tag it is $25.00 to replace.

The tags are assigned to each individual and not to be given to anyone else to use.

*if you wish to cancel your membership, please come in to sign the cancellation form, $150.00 cancelation fee if cancelling with in the lock in term.

Thank you for your Membership, we look forward to helping you both on your fitness and health journey.

The Momentum Fitness Warrnambool Team
1st Member*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
2nd Member*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person:
Name*

First NameLast Name
Phone Number*
Are either of you currently under a Doctor/Physicians Care?*

YesNo
If Yes, please fill out all relevant details.
Physicians Specialty
Does this hinder you from performing any kind of excercise?

YesNo
Doctor or Physicians Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please list any injuries or medical conditions for you both, Add N/A if not applicable*
24/7 Disclaimer and T&C's

Please read this carefully and sign and date if you agree to the T&C's outlined below
First Member Signed*

Clear
Second Member Signed*

Clear
Date*
Once you have completed the form and filled in all relevent information, select the submit button, this will then take you to Debitsuccess, our 3rd party company who handles all of our membership payments.

*Debitsuccess only needs 1 persons information.
When you hit SUBMIT, you wil be redirected to the Debitsuccess Portal where you will set up your payment options.
Should be Empty:

ParQ and Application Form

24/7 Disclaimer and T&C's