Online Form - Membership Application GLC » Busselton Leisure Centre

First Name*

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Surname*

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Address

Street Address:

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City:

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State:

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Post Code:

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Country:

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Mobile Contact Number*

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Email*

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Gender

MaleFemale

D.O.B.*

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Emergency Contact Person*

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Emergency Contact Number*

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This agreement is subject to a 7 day cooling off period. Cancellation of this membership agreement within the time frame specified must be received in writing. A $25 administration fee is applicable to all cancellations. *

Agreed

DECLARATION: I declare that I am in a good state of health and fitness and that there is no medical reason whatsoever that could be regarded as a restriction on or an impediment to my application for membership. I acknowledge that during such times I am on the premises (or its surrounds) both my property and my person shall be at my own risk and I will not hold the City of Busselton (or its employees) liable for any personal injury or loss of property however caused. If I am under 16 years of age, I agree that conditions will be placed on my membership and I shall abide by the said conditions. I acknowledge that the services and programs offered may vary from time to time and be disrupted as a result of maintenance or unforeseen events. In the instance where these events are less than seven consecutive days, I do not have a claim to be reimbursed for the lost time or services during these events. I acknowledge that this is a binding legal agreement and shall not be cancelled by me. I acknowledge that the agreement may not be transferred to any other person without the consent of the City of Busselton.*

Agreed

This is an ongoing membership agreement. The agreement will continue until either you or the supplier terminates it in the way described in the agreement. If an automatic debit arrangement is in place, membership fees will continue to be debited from your credit card or account until you or your fitness centre cancels the arrangement by notifying your bank or credit provider. If you terminate the agreement or stop the automatic debit arrangement in a manner not described in the agreement, then you may be liable to the Leisure Centre for breach of contract.*

Agreed

Membership Holds: Memberships may be placed on hold for minimum of TWO weeks and a maximum of THREE months within a 12 month period. You are required to complete a deferral form in advance before the requested time period.*

Agreed

Membership Cancellations: All cancellations must be received in writing. Confirmation of cancellation will be acknowledged by return email.*

Agreed

Promotional material

I do not wish to receive promotional material

Photos used for promotional purposes

I do not wish for my photo to be used for promotional purposes

If under the age of 18 years, parent/guardian must authorise*

Acknowledged

Please view our Terms and Conditions

Please complete your Pre-exercise Questionaire and submit before completing your membership application.

Membership Type Required*

Full Access (all areas)Gym OnlySwim OnlyGroup Fitness OnlyUnsure

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Duration*

12 months6 months3 months1 monthFortnightly Direct Debit

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Concession Applicable

YesNo

Please provide proof of Concession at time of payment.

(Concession, Seniors, DVA)

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