Contact Information

First Name:
Last Name:
Date of Birth:
Gender:
Occupation:
Email:
Phone:
Mobile:
Postal Address:

How You Heard About Us

How did you hear about Us?		Why did you decide to join?
	Friend/Family		Gym Equipment
	Mail Drop/Flyer		Squash Facilities
	Newspaper Ad		Price/Value for money
	Radio Ad		Location
	Website/Websearch		Staff/Members

Your Health

	I have Diabetes		I've had knee/ankle/etc injuries
	I have Epilepsy		I've had back/neck problems
	I use Medication (specify)		Other, please specify:

Purchase Membership

Please select the type of membership you would like.

	12 months Full Gym Membership for $425
	6 months Full Gym Membership for $280
	3 months Full Gym Membership for $180
	$10 a week no contract offer. $50 fee plus $20 for first two weeks. $70 total.

Purchase Personal Training

Please choose the personal training you want.

	1.0 hr of Personal Training for $55
	4 sessions of Personal Training @ $50 each
	No Personal Training at this stage

Pay by Credit Card

Name on card:
Card number:
Type:	Please Select Visa MasterCard Amex Diners Club
Expiry:	01 02 03 04 05 06 07 08 09 10 11 12 / 09 10 11 12 13 14

Confirmation

I wish to purchase the above membership and confirm that the above details are correct.