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Membership Details

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Next - Additional information

Additional information

ID Number: ID Number field is required

Emergency Contact Name: Emergency Contact Name field is required

Emergency Contact Number: Emergency Contact Number field is required

Occupation: Occupation field is required

Contract Number: Contract Number field is required

Postal Address: Postal Address field is required

Emergency Contact Relationship: Emergency Contact Relationship field is required

Emergency Contact Email: Emergency Contact Email field is required

Parent / Legal Guardian Name and Surname: Parent / Legal Guardian Name and Surname field is required

Parent / Legal Guardian Relationship: Parent / Legal Guardian Relationship field is required

Parent / Legal Guardian Contact Number: Parent / Legal Guardian Contact Number field is required

Parent / Legal Guardian Email: Parent / Legal Guardian Email field is required

Postal Code: Postal Code field is required

PAR-Q Notes : (Please disclose any doubt about partaking in physical activities or health risks ): PAR-Q Notes : (Please disclose any doubt about partaking in physical activities or health risks ) field is required

Medical Aid No: Medical Aid No field is required

Medical Aid Company: Medical Aid Company field is required

Direct Marketing & Related Matters

I consent to White Inc Studio retaining my information and contacting me for the purposes of direct marketing and related matters

Yes Please select marketing preference. No

Next - PAR-Q

PAR-Q

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Medical Readiness Questionnaire

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1. 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?: Select an optionNOYES 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? field is required

2. 2. Do you feel pain in your chest when you do physical activity?: Select an optionNOYES 2. Do you feel pain in your chest when you do physical activity? field is required

3. 3. In the past month, have you had chest pain when you were not doing physical activity?: Select an optionNOYES 3. In the past month, have you had chest pain when you were not doing physical activity? field is required

4. 4. Do you lose your balance because of dizziness or do you ever lose consciousness?: Select an optionNOYES 4. Do you lose your balance because of dizziness or do you ever lose consciousness? field is required

5. 5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?: Select an optionNOYES 5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? field is required

6. 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?: Select an optionNOYES 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? field is required

7. 7. Do you know of any other reason why you should not do physical activity?: Select an optionNOYES 7. Do you know of any other reason why you should not do physical activity? field is required

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Contract Duration: Please select a duration 1 month3 months7 days2 months

Access Level: Please select an Access Level Local

Payment Method: Please select a payment method Debit Order PIF

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