Corporate - Gym Membership Form

The Shire of Coolgardie offers a gym in each town site of  Coolgardie and Kambalda.

Please click here for full terms and conditions

Applicant Information

Title*This field is required.
Gender*This field is required.
Corporate Body*This field is required.
Discount will be applied at confirmation of work or group/club affiliation
Emergency Contact

Emergency Contact

Membership Agreements Type*This field is required.


Monthly Membership Type*This field is required.

Membership Agreements Type

Emergency Personnel are registered active Emergency Service Volunteers -  Western Australian Police Force, St John Ambulance, Kambalda and Coolgardie Volunteer Fire & Rescue Service. 

Photo ID Example

Driver's license, Student ID, Passport, WA photo card, Pension card, Employee Card

Membership Cooling-Off Period

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.

Max File Size: 10.00 MB
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Have you been a member of the Shire of Coolgardie gym?*This field is required.
All Membership access cards and replacements will be charged at $36 each*This field is required.
Corporate Body*This field is required.

Pre-Exercise Screening

Has your Doctor ever told you that you have a heart condition or have you ever suffered a stroke?*This field is required.
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?*This field is required.
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?*This field is required.
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*This field is required.
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?*This field is required.
Do you have any diagnosed muscle, bone, or joint problems that you have been told could be made worse by participating in physical activity/exercise?*This field is required.
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/ exercise?*This field is required.
Agreement Terms and Conditions

Agreement Terms and Conditions

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

I declare that I am medically and physically able to participate in physical activity and understand and accept the inherent risks of undertaking exercise.

I acknowledge and agree that I enter 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 my own risk.

I acknowledge that I have received and read the Terms and conditions of which I agree to observe and be bound by should my application be accepted.

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

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