Online Form - AQUATIC Membership » Coolgardie Shire Council

MEMBERSHIP AQUATIC FACILITY*

COOLGARDIEKAMBALDA

Name of applicant*

Photo identification - Please upload a copy of your photo I.D - Driver’s license, Student ID, Passport, WA photo card, Pension card, WWC, Employee Card*

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

MEMBERSHIP COOLING-OFF PEROID

Client may terminate their membership within 7 days; after the day on which the client enters into the agreement. Administration fees will apply at a pro rata rate to the term of agreement.

Postal Address*

Email address*

Date of birth*

Gender

Home number

Mobile number*

Family Members

YesNo

AQUATIC MEMBERSHIP TYPE

AQUA Monthly

ADULTCONCESSIONCHILDFAMILY

AQUA Flexi

ADULTCONCESSIONCHILDFAMILY

AQUA Season

ADULTCONCESSIONCHILDFAMILYFAM CONCESSION

Please upload evidence for concession

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Has any family member been a member of the Shire of Coolgardie gym?*

YesNo

Is a new FOB, required? (This will be an additional cost) *

YesNo

EMERGENCY CONTACT DETAILS

First name*

Surname

Mobile

PRE-EXERCISE SCREENING

Has your Doctor ever told you or any family member that they have a heart condition or have ever suffered a stroke?*

YesNo

Does any family member or you ever experience unexplained pains in their chest at rest or during physical activity/exercise?*

YesNo

Does any family member or you have ever felt faint or have spells of dizziness during physical activity/exercise that causes them to lose balance?*

YesNo

Has any family member or you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*

YesNo

Has any family member or you have diabetes, (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?*

YesNo

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

YesNo

Does any family member or you have any other medical condition(s) that may make it dangerous to participate in physical activity/exercise?*

YesNo

AGREEMENT TERMS AND CONDITIONS

I understand that IF any questions answered are YES to any of the 7 questions above, I and /or family members should seek guidance from a GP or appropriate allied health professional prior to undertaking Physical Activity and/or Exercise.

I declare that I am, and/or named family members are medically and physically able to participate in physical activity and understand and accept the inherent risks of undertaking exercise.

I, or on behalf of family members, acknowledge and agree, that entry into the Facility and surrounds and/or participate in programs, utilise the equipment and/or take advantage of services offered by Shire of Coolgardie absolutely at each person’s own risk.

I, or on behalf of family members acknowledge that the Terms and conditions have been read and agree to observe and be bound by should this application be accepted.

I declare, to the best of my knowledge that all the information I have provided is complete and correct.

AGREEMENT TERMS AND CONDITIONS

Yes