Membership Application

Complete the details below to create a new member profile

Personal Details

Email: Please enter a valid email address.

Password:

Validate

Forgot Password

Your account has been validated, you may continue.

Name: Please enter a name

Surname: Please enter a surname

Date of Birth: Please select a date of birth in the format YYYY-MM-DD

Age: Please select a date of birth in the format YYYY-MM-DD

Physical Address:

Cell: Please enter a valid cellphone number

Gender: Please select a gender

Next - Membership Details

Membership Details

Next - Additional information

Additional information

ID Number: ID Number field is required

Emergency Contact Name: Emergency Contact Name field is required

Emergency Contact Number: Emergency Contact Number field is required

Occupation: Occupation field is required

Contract Number: Contract Number field is required

Postal Address: Postal Address field is required

Emergency Contact Relationship: Emergency Contact Relationship field is required

Emergency Contact Email: Emergency Contact Email field is required

Parent / Legal Guardian Name and Surname: Parent / Legal Guardian Name and Surname field is required

Parent / Legal Guardian Relationship: Parent / Legal Guardian Relationship field is required

Parent / Legal Guardian Contact Number: Parent / Legal Guardian Contact Number field is required

Parent / Legal Guardian Email: Parent / Legal Guardian Email field is required

Postal Code: Postal Code field is required

PAR-Q Notes : (Please disclose any doubt about partaking in physical activities or health risks ): PAR-Q Notes : (Please disclose any doubt about partaking in physical activities or health risks ) field is required

Medical Aid No: Medical Aid No field is required

Medical Aid Company: Medical Aid Company field is required

Direct Marketing & Related Matters

I consent to CrossFit Redshack retaining my information and contacting me for the purposes of direct marketing and related matters

Yes Please select marketing preference. No

Next - Payment Details

PAR-Q

Next - Payment Details

Contract Duration:

Access Level:

Payment Method:

Next - Membership Details

Eft/Cash