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PERSONAL DETAILS
JOINING ONLINE
MEMBERSHIP RATES
Heart Beats Exclusive over 30's Fitness Studios - Gym Open 24 Hours, 7 Days a Week.
HEART    BEATS
f i t n e s s    s t u d i o s
Fill out the form then click submit. It's that simple.
(Note for Joint Memberships please fill in two forms)
Mr.
Mrs.
Miss.
Ms.
Dr.
Title.
First Name.
Last Name.
Address 1.
City.
Address 2.
State.
Postcode.
Gender.
Male.
Female.
Birth Date.
Tel Home.
Tel Work.
Cell Phone.
Email.
Emergency
Contact Name.
Emergency Contact No.
MEDICAL HISTORY (Please Click if any of the following apply)
Type 1 Diabetes.
Type 2 Diabetes.
Heart Disease.
Heart Attack.
Heart Murmur.
Dizziness / Fainting.
Epilepsy / Seizures.
High Blood Pressure.
Low Blood Pressure.
Asthma.
Other Lung Problems.
Arthritis.
Foot Problems.
Limited Range of Motion.
Stroke.
Migraines.
Persistent Fatigue.
Stomach Problems.
Cancer Surgery.
Hernia.
Cigarette Smoker.
High Cholesterol.
Overweight.
Knee Problems.
Back Problems.
Are you Pregnant?
Has a Doctor or Physio imposed any exercise restrictions? If so, please describe:
Please indicate any other Medical Conditions or Restrictions that you may have:
MEMBERSHIP DETAILS   (please click)
Membership.
Silver.
Gold.
Platinum.
Option.
Type.
Payment.
Single.
Joint (Spouse).
Peak.
Off-Peak.
Annually.
Weekly/Monthly Payments.
MEMBERSHIP FEES   (please click)
Joining Fee - $100
Debit from Bank.
Debit from C/Card.
Cheque.
Annual Payment.
Debit from Bank.
Debit from C/Card.
Cheque.
Weekly/Monthly Payments.
Debit from Bank.
4 Weekly.
Weekly.
Fortnightly.
Monthly.
Payment frequency.
HOW DID YOU HEAR ABOUT US?   (please click)
Mail.
Internet.
Newspaper.
TV Advert.
Signage.
Doctor Referral.
Studio Member.
Other.
I have read Heart Beats Fitness Stuido Terms and Conditions
Recently Broken Bones.
Circulation Problems.
FRANCHISE OPPORTUNITY
Debit from C/Card.     (NO Cash or Chq)