$20.00 12mth Lock In- ParQ and Application form

ParQ and Application Form

MOMENTUM FITNESS WARRNAMBOOL
Your membership with Momentum Fitness Warrnambool includes

- Fitness Program

- $65.00 Joining Fee including 24/7 Access Fob

- Full access to Gymnasium

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

*if you wish to cancel your membership before the Lock in period ends, a $150.00 cancellation fee will apply. If you cancel after the 12months locked in term and before the end of contract date, please come in and sign a cancellation form.

*If you need to suspend your membership a $5.00 per week fee will apply. Suspending will lengthen the term of your lock in period.

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

The Momentum Fitness Warrnambool Team
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email address*
Age*
Date of Birth*

DayMonthYear
Height
Weight
Emergency Contact Person:
Name*

First NameLast Name
Phone Number*
Are 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, 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
Name of Parent or Guardian if under 17

First NameLast Name
Parent or Guardian sign if under 17

Clear
Date*
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