5D Membership Agreement

5D Membership Agreement
Name*

First NameLast Name
5D Location*

TemplestoweMitcham
Email*
example@example.com
Address*

Street Address

Suburb

CityState / Province

Postal / Zip Code
Date of Birth*

DayMonthYear
Date
Best Contact Number*
Emergency Contact (Name and Number)*
Membership*

$1,199 - 12 Month Upfront (Class & Gym Access)$799 - 12 Month Upfront (Gym Access Only)$30 per week Direct Debit - 6 Month Contract (Class & Gym Access)$37 per week Direct Debit - No Contract (Class & Gym Access)$15 per week Direct Debit - 6 Month Contract (Gym Access Only)$18 per week Direct Debit - No Contract (Gym Access Only)$179 - 10 Access Pass (Class & Gym Access)
*If you are singing up for a direct debit membership, please fill in either your Credit Card details OR Bank Account details below

This will be the account funds will be debited from (Funds can not be debited from a savings account)
Name on Card:Type here
Card Number:Type here
Expiry (mm/yy):Type here
Bank Account Name:Type here
BSB:Type here
Account Number:Type here
Billing Frequency

WeeklyFortnightlyMonthly (Calendar Month)
Membership Start Date

DayMonthYear
Date
Please provide any health conditions (past and present) that may affect your health when exercising. 5D Health & Fitness Pty Ltd recommend you seek medical advice and clearance from your GP or allied health professional prior to exercising.
Signature (Use finger or mouse to sign)

Clear
Please verify that you are human*
Should be Empty: