Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Membership Day and Time

Monday 14.00-16.30

Monday 18.00-20.30

Tuesday 10.00-12.30

Tuesday 14.00-16.30

Tuesday 18.00-20.30

Wednesday 10.00-12.30

Wednesday 14.00-16.30

Wednesday 18.00-20.30

Thursday 10.00-12.30

Thursday 14.00-16.30

Thursday 18.00-20.30

Friday 10.00-12.30

Friday 14.00-16.30

Friday 18.00-20.30

Start Date *

MM

DD

YYYY

I have read and agree to the Handbook *

Yes

I have set up my Direct Debit *

Once submitted the Direct Debit will be setup within 7 days and future payments will be collected on or just after the 1st of the month

Yes