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Membership Application

Personal Details

Price Presenter

Complete the details below to create a new member profile

Personal Details

Email: Please enter a valid email address.

Scan

Password:

Validate

Forgot Password

Your account has been validated, you may continue.

Name: Please enter a name

Surname: Please enter a surname

ID number: ID number field is required

Date of Birth: Please select a date of birth in the format YYYY-MM-DD

Search Address via Google:

Street address

Street Name

Suburb

City

Postal Code

Country

Contract Number: Valid Contract Number Between 5 and 10 Digits

Cell: Please enter a valid cellphone number

Gender:

Next - Price Presenter

Membership Details

Next - Additional information

Additional information

Medical Aid No: Medical Aid No field is required

Emergency Contact Number: Emergency Contact Number field is required

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

PAR-Q Notes: PAR-Q Notes field is required

Emergency Contact Name: Emergency Contact Name field is required

Emergency Contact Email: Emergency Contact Email field is required

Postal Code: Postal Code field is required

Emergency Contact Relationship: Emergency Contact Relationship field is required

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

Postal Address: Postal Address field is required

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

Medical Aid Company: Medical Aid Company field is required

Occupation: Occupation field is required

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

Direct Marketing & Related Matters

I consent to Itensity 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

Cardiovascular Disease

1. Does your family have any pre existing heart disease?: Does your family have any pre existing heart disease? field is required

General Health

2. Do you have diabetes: Do you have diabetes field is required

3. are you dead: are you dead field is required

Health Questions

4. Are you dead: Are you dead field is required

Next - Payment Details

Contract Duration:

Access Level:

Payment Method:

Next - Membership Details

How will you be paying:

Debit Order

EFT / Cash

Bank Details

These debit details belong to:

This member

Someone else

A Company

Company registration No: Please enter the company registration number

Company Name: Please enter the company name

Company email address: Please enter the company email address

Account Holder / Contact Person ID / Passport Number: Please enter the account holder id number

Account Holder / Contact Person Cell: Please enter the account holder cell number

Account Holder / Contact Person Initials: Please enter the account holder Initials

Account Holder / Contact Person Surname: Please enter the account holder surname

Bank:

Card Number: Please enter the correct credit card number.

Card Expiry Date: Please enter the card expiry date

Branch Code: Please enter a valid branch code

Bank Account Number: Please enter a valid account number

Account Type: Select a valid account type

Preferred Debit Date:Select a valid debit date

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