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You have selected <%membership_package.name%> at <%centre_details.name%>.

Membership Type - <%membership_package_cost.membership_type_name[0].membership_type_name%>.

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$<%customer_billing_details.selected_frequency_amount%> $<%setPriceForSelectedFrequency(customer_billing_details.payment_frequency, membership_package_cost.price)%> Weekly $<%promotional_code.new_total%> $<%membership_package_cost.price + customer_billing_details.joining_fee%> OneOff

$<%promotional_code.calculated_dd < 0 ? 0 : promotional_code.calculated_dd%> $<%(membership_package_cost.price + customer_billing_details.joining_fee) < 0 ? 0 : (membership_package_cost.price + customer_billing_details.joining_fee)%> First

<%centre_details.name%>

<%membership_package.name%>

<%promotional_code.promo_code.sentence%>

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Apply Remove

Fees

Select Payment Frequency:

<%t%>

Trial Cost

<%(promotional_code.promo_code.cost == null ? 0 : promotional_code.promo_code.cost) | currency%>

Joining Fee

<%customer_billing_details.joining_fee | currency%> <%promotional_code.new_joining_fee | currency%>

Pro-Rata Fee

<%customer_billing_details.pro_rata_amount | currency%> <%promotional_code.new_pro_rata_amount | currency%>

Month to Month <%membership_package_cost.term%> <%membership_package_cost.unit%> <%membership_package_cost.term%> <%membership_package_cost.unit%> <%membership_package_cost.no_of_vp%> visit passes
<%membership_package_cost.vp_expiry_in_months%> Months
(<%membership_package_cost.membership_name%>)

$<%setPriceForSelectedFrequency(customer_billing_details.payment_frequency, membership_package_cost.price)%> $<%customer_billing_details.selected_frequency_amount%> (<%customer_billing_details.payment_frequency%>) <%membership_package_cost.price | currency%> <%(promotional_code.new_weekly < 0 ? 0 : promotional_code.new_weekly) | currency%> (OneOff)

First Payment

<%customer_billing_details.payment_date%>

<%membership_package_cost.price + customer_billing_details.joining_fee + customer_billing_details.new_pro_rata_amount | currency%> <%promotional_code.calculated_dd + promotional_code.new_pro_rata_amount | currency%>

First Payment

<%customer_billing_details.payment_date%>

Payments

<%customer_billing_details.trial_cost_debit_date%>

<%customer_billing_details.payment_date%>

<%customer_billing_details.trial_cost | currency%>

<%customer_billing_details.joining_fee + customer_billing_details.pro_rata_amount + membership_package_cost.price | currency%> <%customer_billing_details.pro_rata_joining_and_weekly_amount | currency%>

Payments

<%customer_billing_details.prorata_joining_fee_debit_date%>

<%customer_billing_details.payment_date%>

<%customer_billing_details.trial_and_joining_fee_debit_date%>

<%customer_billing_details.pro_rata_debit_date%>

<%customer_billing_details.weekly_debit_date%>

<%customer_billing_details.joining_fee + customer_billing_details.pro_rata_amount | currency%> <%promotional_code.new_joining_fee + customer_billing_details.new_pro_rata_amount | currency%> <%customer_billing_details.joining_fee + promotional_code.promo_code.cost | currency%> <%customer_billing_details.trial_cost_joining_fee | currency%>

$<%setPriceForSelectedFrequency(customer_billing_details.payment_frequency, membership_package_cost.price)%> $<%customer_billing_details.selected_frequency_amount%> <%customer_billing_details.pro_rata_amount | currency%> <%promotional_code.new_pro_rata_amount | currency%>

$<%setPriceForSelectedFrequency(customer_billing_details.payment_frequency, membership_package_cost.price)%> $<%customer_billing_details.selected_frequency_amount%>

Payments

<%promotional_code.promo_code.specific_charge_date%>

<%membership_package_cost.price + customer_billing_details.joining_fee + customer_billing_details.pro_rata_amount | currency%> <%customer_billing_details.accrue_weekly_fee | currency%>

OneOff Payment

<%customer_billing_details.payment_date%>

<%membership_package_cost.price + customer_billing_details.joining_fee | currency%> <%promotional_code.new_total | currency%>

Expiry Date

<% customer_billing_details.upfront_end_date %> <%promotional_code.new_upfront_end_date%>

Total min cost <%total_minimum_cost_for_direct_debit | currency%> over Month to Month <%membership_package_cost.term%> <%membership_package_cost.unit%>

YOUR DETAILS

<% error %>

Email *

First Name *

Last Name *

Gender *

Mobile number *

Date of birth *

Postal address *

Address

Suburb

City

State

Country

PostCode

Emergency contact

Emergency Name *

Emergency Mobile number *

Promo Code
<%promotional_code.promo_code.sentence%>

<% error %>

Continue

TERMS AND CONDITIONS

I declare that I am over the age of 18 and I agree to the <%direct_debit_value%> Upfront Terms and Conditions.

I agree to the Centre Terms and Conditions.

I / We authorise Ezidebit Pty Ltd ACN 096 902 813 (User ID No 342190, 342191, 428198) to debit my/our account at the Financial Institution identified above through the Bulk Electronic Clearing System BECS in accordance with this Direct Debit Request

PAYMENT

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Promo Code
<%promotional_code.promo_code.sentence%>

<% error %>

Account Type *

Account Holder *

Account Country *

BSB *

Account Number Credit Card Number *

Credit Card Type *

Expiry Date *

<% error %>

Continue

SUMMARY

<%centre_details.name%>

<%membership_package.name%>

<%promotional_code.promo_code.sentence%>

<% error %>

Apply Remove

Fees

Select Payment Frequency:

<%t%>

Trial Cost

<%(promotional_code.promo_code.cost == null ? 0 : promotional_code.promo_code.cost) | currency%>

Joining Fee

<%customer_billing_details.joining_fee | currency%> <%promotional_code.new_joining_fee | currency%>

Pro-Rata Fee

<%customer_billing_details.pro_rata_amount | currency%> <%promotional_code.new_pro_rata_amount | currency%>

First Payment

<%customer_billing_details.payment_date%>

First Payment

<%customer_billing_details.payment_date%>

Payments

<%customer_billing_details.trial_cost_debit_date%>

<%customer_billing_details.payment_date%>

<%customer_billing_details.trial_cost | currency%>

Payments

<%customer_billing_details.prorata_joining_fee_debit_date%>

<%customer_billing_details.payment_date%>

<%customer_billing_details.trial_and_joining_fee_debit_date%>

<%customer_billing_details.pro_rata_debit_date%>

<%customer_billing_details.weekly_debit_date%>

$<%setPriceForSelectedFrequency(customer_billing_details.payment_frequency, membership_package_cost.price)%> $<%customer_billing_details.selected_frequency_amount%> <%customer_billing_details.pro_rata_amount | currency%> <%promotional_code.new_pro_rata_amount | currency%>

$<%setPriceForSelectedFrequency(customer_billing_details.payment_frequency, membership_package_cost.price)%> $<%customer_billing_details.selected_frequency_amount%>

Payments

<%promotional_code.promo_code.specific_charge_date%>

<%membership_package_cost.price + customer_billing_details.joining_fee + customer_billing_details.pro_rata_amount | currency%> <%customer_billing_details.accrue_weekly_fee | currency%>

OneOff Payment

<%customer_billing_details.payment_date%>

<%membership_package_cost.price + customer_billing_details.joining_fee | currency%> <%promotional_code.new_total | currency%>

Expiry Date

<% customer_billing_details.upfront_end_date %> <%promotional_code.new_upfront_end_date%>

Total min cost <%total_minimum_cost_for_direct_debit | currency%> over Month to Month <%membership_package_cost.term%> <%membership_package_cost.unit%>

<% error %>

Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?

Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?

Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?

Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

#	Questions	Answer
1	Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?	Yes No
2	Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?	Yes No
3	Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?	Yes No
4	Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?	Yes No
5	If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?	Yes No
6	Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?	Yes No
7	Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?	Yes No

Upload Health Certificate:

If you have answered "NO" to all of the questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise.

I agree that if any of the information declared (above or herein) changes following the submission of this form, I will inform the centre and present for additional assessment in person by authorised staff before continuing to use the facilities. *

I believe that to the best of my knowledge, all the information I have supplied is correct. *

<%centre_details.name%>

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YOUR DETAILS

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<%centre_details.name%>

Customise your membership

Choose your membership term

Choose your membership type

Show Summary

YOUR DETAILS

TERMS AND CONDITIONS

PAYMENT

SUMMARY

Verify Email

Check Your Email

Enter the code that we sent to Be sure to check your junk or spam folder

The code is valid for 15 minutes

Enter the code that we sent to
Be sure to check your junk or spam folder