Online Form - Gym Membership

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

Please click here for full terms and conditions

Maximum size of ALL attachments is 976.56 MB

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.

GYM MEMBERSHIP TYPE *
Maximum size of ALL attachments is 976.56 MB
Have you been a gym member before? *
Is a new FOB, required? (This will be an additional cost) *

EMERGENCY CONTACT DETAILS

PRE-EXERCISE SCREENING

Has your Doctor ever told you that you have a heart condition or have you ever suffered a stroke? *
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? *
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? *
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? *
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? *
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? *

AGREEMENT TERMS AND CONDITIONS

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

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 / Exercise at the Shire of Coolgardie Gym Facilities and that I require a medical clearance to be eligible to receive an exercise program prescribed to me by a qualified gym instructor.

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 .

AGREEMENT TERMS AND CONDITIONS *