Membership Application

Complete the details below to create a new member profile

Personal Details

ID number: Please enter a valid id/passport number

Password:

Validate

Forgot Password

Your account has been validated, you may continue.

Name: Please enter a name

Surname: Please enter a surname

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

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

Physical Address:

Cell: Please enter a valid cellphone number

Gender: Please select a gender

Next - Price Presenter

Membership Details

Select a Benefit:

Next - Additional information

Additional information

Emergency Contact Email: Emergency Contact Email field is required

Vitality Number: Vitality Number field is required

Medical Aid Company: Medical Aid Company field is required

Medical Aid No: Medical Aid No field is required

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

Postal Code: Postal Code field is required

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

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

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

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

Email: ID number field is required

Emergency Contact Relationship: Emergency Contact Relationship field is required

Postal Address: Postal Address field is required

Contract Number: Contract Number field is required

balance: balance field is required

visits: visits field is required

promocode: promocode field is required

cardownerno: cardownerno field is required

Occupation: Occupation field is required

Emergency Contact Number: Emergency Contact Number field is required

Emergency Contact Name: Emergency Contact Name field is required

Direct Marketing & Related Matters

I consent to Moove - Cosmos 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

Par-Q

1. The member acknowledges that at the time of signing this contract they have no medical ailments which would be detrimental to their health while making use of any and all gym facilities and further warrants that should they become of any such ailments they will notify the gym staff. : The member acknowledges that at the time of signing this contract they have no medical ailments which would be detrimental to their health while making use of any and all gym facilities and further warrants that should they become of any such ailments they will notify the gym staff. 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 Date of Birth: Please enter the account holder date of birth

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

You will complete your credit card details after clicking submit

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