Membership Form



 

Complete the details below to create a new member profile

Personal Details

Please enter a valid id/passport number
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

Please select a tariff

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

PAR Q Questionnaire


Advanced arteriosclerosis field is required
EMS Training will only be permitted for the following conditions after obtaining medical approval from your Doctor. field is required
Osteoarthritis (joint diseases) field is required
Severe Circulatory disorder field is required
Medical Approval letter from you Doctor should you have any of the listed below: field is required
Acute Arthritis (Rheumatoid) field is required
Abdominal wall hernia or inguinal hernia field is required
Diabetes Mellitus field is required
Tumours/Cancer field is required
Cardiovascular diseases field is required
Tuberculosis field is required
I acknowledge and accept that I am conducting the Miha-Bodytec device entirely at my own risk. field is required
Diseases of internal organs (Kidneys, liver etc) field is required
Stroke field is required

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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