header-mint-opening-soon
2011 Membership Application Form
  1. (*)
    Invalid Input
  2. Surname:(*)
    Invalid Input
  3. First Name:(*)
    Invalid Input
  4. Phone:
    Invalid Input
  5. Mobile:
    Invalid Input
  6. Birthdate:(*)
    Invalid Input
  7. Address:(*)
    Invalid Input
  8. Email:(*)
    Invalid Input
  9. Emergency Contact Name:(*)
    Invalid Input
  10. Emergency Contact Number:(*)
    Invalid Input

  11. Your membership agreement is an ongoing agreement with a minimum initial commitment period of at least twelve weeks. Your membership will automatically renews for a further twelve week commitment period unless terminated under paragraph 8 of the membership policy. Basically this means your contract will roll over every twelve weeks unless you tell us not to please take the time to look at our full membership policy at www.mintfit.co.nz, or on the club wall.

  12. Membership Start Date(*)
    Invalid Input
  13. I ...................................................... hereby acknowledge that I have read, understood and will abide by the application, membership rules and payment schedule of $_______ per fortnight via Direct Debit payments.

    Signed............................................ Date ............

  14. (*)
    Invalid Input