Club Membership Registration Form

Project Club Membership Registration

Complete the form below to sign up for our membership service.
Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Post Code
Birth Date:*

DayMonthYear
Terms and Conditions of Membership, please read carefully
You have chosen the Restore Membership, which is maximum of 6 body treatments in a calendar month. Which term and payment plan would you like (one Treatment is usually $65!)*
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12 Month Term - weekly($52.00NZD for each week)

12 Month Term($104.00NZD for each two weeks)

12 Month Term($225.00NZD for each month)

Open Term ($60.00NZD for each week)

Open Term ($120.00NZD for each two weeks)

Open Term ($260.00NZD for each month)
Direct Debit payment details:
Bank Account
Name of Account
I hereby give authority to have my direct debit set up by Project Physique via Gocardless.
Thanks for filling out this form, your application will be processed shortly.
Should be Empty: