Gym New Member Registration Form

Business/Company Name: *

Personal Details

First Name: *

Middle Name(s):

Surname: *

Date of Birth: *

Mailing Address: *

City *

State: *

Zip Code: *

Phone (Home): *

Phone (Cell / Mobile): *

Email: *

Do you declare a disability? *

Please specify: *

Where did you learn about the club? *

If Other please specify: *

Emergency Contact Details

Emergency Contact 1 Name: *

Emergency Contact 1 Telephone: *

Relationship: *

Emergency Contact 2 Name: *

Emergency Contact 2 Telephone: *

Relationship: *

Membership

Please indicate the type of membership you require: *

Membership Duration: *

If Other please specify: *

How would you like to pay for your membership? *

If Other please specify: *

Photo (Please upload a photo for your membership ID): *

Signature: *

Tap or click on the signature above to sign

Payment Agreement

Type of charge *

Recurring Charge
You authorize regularly scheduled charges to your Credit Card or Bank Account. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your Credit Card or Bank Account Statement. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.

One Time (1) Charge
You authorize the merchant below to make a one-time charge to your Credit Card or Bank Account listed below. By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

I...

Full Name: *

authorize the company named on this form to charge my credit card or bank account below

for: *

$

beginning on: *

on: *

Billing Details

Billing Address: *

Zip Code: *

Credit Card / Bank Account Information

Would you like to use a Credit Card or Bank Account? *

Card Type: *

Visa MasterCard AMEX Discover

Cardholder's Name: *

Credit Card Number: *

Expiration Date: *

(MM/YY)

Security Code (CVV) *

Type of Bank Account: *

Checking Account Savings Account

Name on Account: *

Bank Name: *

Account Number: *

Routing Number: *

Signature: *

Tap or click on the signature above to sign

For Office Use Only

Induction Date: *

Membership Number: *

Membership Type: *

Payment Type: *

Staff Member’s Signature: *

Set a reminder: