AZPT Registration Form

Please select AZPT Service:

Personal Information

Name

First NameLast Name

Birth Date

MonthDayYear

Gender

Other

Contact Number

Area CodePhone number

E-mail

Address

Street Address

Street Address Line 2

CityState

Post CodeCountry

Emergency Contact Name

First NameLast Name

Emergency Contact Number

Area CodePhone Number

The following information will provide me the information required to create the best possible training program and enviroment to suit your health and fitness needs.

Medical Information

Medical Checklist

If you selected any of the above, please specify:

Do you have Private Health Insurance?

If yes, please record policy number

Policy Name/ Number

Occupation

Long Term Goal - 12months

Mid Term Goal - 6months

Short Term Goal - 8 weeks

PAYMENT INFORMATION

Payments can be made by cash on arrival or by direct deposit into the following account:

BANK DETAILS

ACC Number: 078 844640

BSB: 105 - 135

Confirmation

1) You hereby confirm to AZ Training that, to the best of your knowledge, you do not have any physical, medical or other disability or condition which may be affected or aggravated by, or which may result in any sickness, injury or death to you as a result of, your inclusion in any AZ Training sessions.

2) You acknowledge that whilst every attempt is made to ensure that the training environment AZ Training provides is safe, there are some significant and inherent risks involved, and you agree that you are participating voluntarily at your own risk and responsibility, thereby exposing yourself to certain risks.

3) You agree to make payment prior to commencing your first training session as per your training selection.

By acknowledging and signing below, I am delivering an electronic signature that will have the same effect as an original manual paper signature and be equally binding to the above statements.

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Email: az.training@hotmail.com

Phone: 0427 795 925

Signature