First Step - Complete The Form
TELL US ABOUT YOURSELF
Title
*
Select One
Full Name
*
Email
*
Phone
*
Do you have a South African ID Number?
*
Yes
No
ID Number
Your Passport Number or Date of Birth
Address
Street Address
City
State
Country
Country
Postal Code
Emergency Contact Name
*
Emergency Contact Number
*
Which coach introduced you to the gym?
*
Select One
If you selected "Other" for "Which coach introduced you to the gym" please elaborate: (i.e. friend, Facebook, flyer, etc)
CONTRACT SELECTION
Select Your Contract Type
*
Select One
Contract Selection - Group Training
Select One
Contract Selection - Semi-Private Training (Plus R 299 gym fee pm)
Select One
DEBIT ORDER
Accountholder Name
*
Bank Name
*
Branch Name
*
Branch Number
*
Type of Account
*
Select One
Account Number
*
Chronic conditions
Have you suffered or continue to suffer from any Chronic health emergencies or conditions?
*
Choose One
You selected Yes for Chronic health emergencies or conditions, please tick any box that applies:
Any heart event or surgery
Stroke
Cancer
Diabetes
Asthma
Hypertension
Other
You selected "heart event or surgery", please elaborate:
You selected "other" for Chronic health emergencies or conditions, please elaborate:
Symptoms
Do you suffer from any of the following symptoms? Tick all that apply:
Pain in chest, neck, jaw, upper back or upper limb while exercising
Abnormal shortness of breath at rest
Dizziness, faintness or blacking out during exercise
Swollen ankles
Abnormal heartbeat or palpitations
Lengthy calf or leg pain after exercise
I confirm that I do not experience any of the above symptoms.
Yes
Prescription medication
Do you take any prescription medication?
*
Choose One
You selected Yes for prescription medication, please let us know which medication and daily dose:
Pregnancy
Are you pregnant or 6 weeks post natal?
*
Choose One
Acknowledgement and consent
I am in good health and physical condition to continue with a physical exercise program.
*
Yes
I consent to disclosing the above health information for the purpose of entering into the Performance Purist gym to commence physical exercise training sessions, as guided by the gym and its trainers.
*
Yes
Please read and agree to the following terms:
Sessions are not transferable.
*
I understand and agree
We bill in arrears and there is a 30-day cancellation notice.
*
I understand and agree
A once-off activation fee of R 499 is added to your first debit order
*
I understand and agree
No downgrades during December and January
*
I understand and agree
Submit Your Information
