Membership Application



 

Complete the details below to create a new member profile

Personal Details

Please enter a valid email address.
Please enter a name
Please enter a surname
Please select a date of birth in the format YYYY-MM-DD
Please enter a valid cellphone number

Membership Details


Additional information

Postal Code field is required
Emergency Contact Name field is required
Emergency Contact Relationship field is required
Parent / Legal Guardian Email field is required
ID Number field is required
Postal Address field is required
Parent / Legal Guardian Contact Number field is required
Medical Aid Company field is required
Contract Number field is required
Parent / Legal Guardian Relationship field is required
Medical Aid No field is required
Occupation field is required
Parent / Legal Guardian Name and Surname field is required
PAR-Q Notes field is required
Emergency Contact Number field is required
Emergency Contact Email field is required

Direct Marketing & Related Matters

I consent to CrossFit Platinum retaining my information and contacting me for the purposes of direct marketing and related matters

Please select marketing preference.

How will you be paying:

Bank Details

These debit details belong to:
Please enter the account holder Initials
Please enter the account holder surname
 
Please enter a valid branch code
Please enter a valid account number
 
Select a valid account type
Select a valid debit date
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