Personal DetailsName *FirstLastDate Of Birth *ID Number/Passport *E-Mail Address *Contact Number *Address InformationPhysical Address *AddressCityProvinceCountrySouth AfricaCityBoksburgGermistonBrakpanBenoniTembisaSpringsAlbertonOtherSuburbRondebuiltDawn ParkVosloorusKlipportjieWindmillVilla LizaLeondaleElsparkSunward parkOtherPrevious Gym:How did you find out about usWebsiteFamily or FriendsPassing ByPamphletSocial MediaWho referred you to Gym Clinic?NextMembership OptionsPlease note that the first payment will be at the gym (card payment / cash / EFT) and if you choose contract membership, the second payment will be collected via debit order.Membership Options *1 Year Contract6 Month Contract2 Year Contract1 Year "family" of 3 ContractAdult Month-to-MonthStudents Month-to-Month4 Months Upfront1 Year Upfront1 Day MembershipPreviousNextEmployer Name *Employment Address *AddressCityProvincePostal CodeAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia (Republic of)MadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States of AmericaUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweCountryCopy of ID/Passport *Proof of Residence *PreviousNextFinal AgreementName *FirstLastResidential Address *AddressCityProvinceCountry South AfricaCity BoksburgGermistonBrakpanBenoniTembisaSpringsAlbertonOtherSuburb RondebuiltDawn ParkVosloorusKlipportjieWindmillVilla LizaLeondaleElsparkSunward parkOtherContact Number *Date *ToBank Name *Capitec BankFNBABSAStandard BankDiscovery BankBank Account Holder *Branch Name *Branch NumberAccount Number *Account Type *ChequeSavingsPreferred Debit Order Day *1st15th25th28thDebit Order Amount *R190Debit Order Amount *R230Debit Order Amount *R150Debit Order Amount *R450Authority to Debit Mandate: *I agree to the terms of the debit order as indicated below: As an authorised signatory of the bank account (or any other account to which I may transfer) I authorise Gym Clinic Proprietary Limited to debit the fees, associated amounts and/or monthly instalments for the duration of the Contract, unless reimbursed and/or paid for upfront by cash or card. If this authority is cancelled, I acknowledge that such cancellation will not automatically cancel the Contract and I/the member will remain liable for payment and any other charges which will be imposed by Gym Clinic Proprietary Limited against myself. I undertake to ensure that funds will be available and authorise Gym Clinic Proprietary Limited to re-submit the debit and/or implement tracking on this account and collect funds as soon as they are available if the debit is unsuccessful. I acknowledge that the bank may charge additional fees for re-submission or failed transaction or disputed transactions, and Gym Clinic Proprietary Limited may recover such fees from me which may amount from a minimum amount of R50.00 (Fifty Rands). I acknowledge that I am not entitled to any refund while this authority is in force, if such amounts were legally owing to Gym Clinic Proprietary Limited. I authorise Gym Clinic Proprietary Limited to disclose to any credit bureau any information concerning this credit profile and payment history. The bank details provided must be for a bank branch in the country of Gym Clinic Proprietary Limited. The debit will appear as “Gym Clinic…” ending with your contract number on the account holder's bank statement. The first debit will be determined by the start date of the membership and that subsequent debits will run on or about the dates chosen above.Gym Clinic Debit Order Terms and Conditions *I agree to the terms of the debit order as indicated below: If I cancel before agreed on period, a cancellation fee of 60% is payable to Gym Clinic. I understand and acknowledge that my membership is subject to the full terms and conditions, the Privacy Policy and The Rule Book, all of which can be viewed via the Gym Clinic website. Gym Clinic may cancel my membership if I do not comply with my contract. There are risks associated with exercising and using gym equipment which can result in serious injury and even death. I accept responsibility for such risks. We recommend that you seek medical advice before you start a new exercise regime and that you always exercise to a level that is appropriate, given your knowledge of your health and any medical advice that you have obtained. I accept all risk and responsibility for nutritional, exercise or any other advice or plans that may be recommended to me. I accept it is my responsibility to ensure that I am medically fit to exercise, and I will seek medical advice if I am unsure of my medical condition. I understand and agree to the following disclaimer: To the fullest extent permitted by law, Gym Clinic Proprietary Limited, and/or its directors, employees and independent contractors (collectively, ‘Gym Clinic’) shall not be liable for any loss or damage whatsoever and howsoever arising (including from any nutritional, exercise or any other advice) suffered by me or any of my dependents, including (without limitation) loss or damage to person or property from a negligent (other than a grossly negligent) act or omission of Gym Clinic, other members or guests. Gym Clinic Contract Terms and Conditions *I have read and fully agree to the Medical Terms and Conditions of Gym Clinic servicesGym Clinic Non-Contract Terms and Conditions *I have read and fully agree to the Terms and Conditions of Gym Clinic servicesSignature to be signed at the gym for final confirmationClear SignaturePreviousNameRegister