Family 2 & 2 - 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 and Classes

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.

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

The Momentum Fitness Warrnambool Team
Parent 1*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Parent 2*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Child 1*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Child 2*

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 you or any of your family 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 whole family, 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
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 parents 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