Membership Form

Complete the details below to create a new member profile

Personal Details

Email: Please enter a valid email address.

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

Physical Address:

Contract Number: Valid Contract Number Between 5 and 10 Digits

Cell: Please enter a valid cellphone number

Gender:

Next - Membership Details

Membership Details

Tariff: Please select a tariff

Next - Additional information

Additional information

Postal Address: Postal Address field is required

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

Occupation: Occupation field is required

Parent / Legal Guardian Relationship: Parent / Legal Guardian Relationship 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

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

Next - Par-Q

Cardiovascular Disease

Do you have a heart condition?: Do you have a heart condition? field is required

General Health

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

Health Questions

Are you dead: Are you dead field is required

Next - Payment Details

How will you be paying:

Debit Order

Eft/Cash

Bank Details

These debit details belong to:

This member

Someone else

Account holder ID no: Please enter the account holder id number

Account holder Cell: Please enter the account holder cell number

Account holder Initials: Please enter the account holder Initials

Account holder Surname: Please enter the account holder surname

Bank:

Branch code: Please enter a valid branch code

Account number: Please enter a valid account number

Account type: Select a valid account type

Debit Date:Select a valid debit date

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