Membership Form — mnbjjglasgow

Name

First Name

Last Name

Date of birth

YYYY

Mobile

Address

Town / City

Postcode

Consent to use your photograph

Yes

Consent to receive First Aid

Yes

Emergency Contact

Name

First Name

Last Name

Mobile

Relationship

Medical Questionnaire

If you answer 'yes' to any of the following questions please check the appropriate box.

History of heart problems, chest pain or stroke?

High blood pressure?

Any chronic illness or condition?

Recent surgery in the pass 12 month?

Pregnancy (now or within last 3 months) ?

History of breathing or lung problems?

Muscle, joint, or back disorder, or any previous injury still affecting you?

Diabetes or thyroid conditioning?

Terms & Conditions

I understand that whilst every care will be taken to give safe instruction, I accept full responsibility and consider myself fit to exercise. I have answered all questions correctly and all medical and health considerations are noted above. Please note it is your responsibility to inform your individual instructor of any medical condition that may affect your health whilst under their instruction as the information declared on this form is not passed on to anyone.

Consent

I agree to the above Terms & Conditions

Direct Debit Details

Full membership unlimited classes £65 Monthly. We will be collecting your membership fee via Direct debt on the first of every month. Your first month membership is paid on your first day at the gym, cash or card. Cancellation of Membership: You must give MNBJJ 2 weeks notice to cancel your membership and stop your direct debt.

Name

First Name

Last Name

8 Digits Account Number:

6 Digits Sort Code:

Consent

I agree to the monthly DD

Date

YYYY

MNBJJ Membership Form