Membership sign up form Step 1 of 3 - Page 1 0% Explosive Functional Fitness Pty Ltd 2014/096704/07 BANK DEBIT ORDER INSTRUCTIONName* First Last Identity Number* Cell*Email* Enter Email Confirm Email Date Of Birth*Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Address Street Address Address Line 2 City ZIP / Postal Code Referral source*Referral sourceCurrent memberFriendFacebookInstagramTwitterEmailMember name* Membership FeeYour membership R799.00 pmDebit Order AuthorisationCurrent Date* MM slash DD slash YYYY Debit Amount R799.00 pmCommencement Date* MM slash DD slash YYYY Abbreviated name as registered with the bank: EXPFUNFITBBank Name*Your bank detailsABSABIDVESTCAPITECINVESTECFNB/RMBNEDBANKMERCANTILEPOSTBANKSTANDARD BANKBANK WINDHOEKBranch Branch No Account Name* Account No* Type of Account A/C*SavingsCurrentTransmissionThis signed Authority and Mandate refers to our contract as dated as on signature hereof ("the Agreement"). I / We hereby authorize you to issue and deliver payment instructions to the bank for collection against my / our abovementioned account at my / our above mentioned bank (or any other bank or branch to which I / We may transfer my / our account) on condition that the sum of such payment instructions will never exceed my / our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me / us by giving you notice in writing of no less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above. The individual payment instructions so authorised to be issued must be issued and delivered as follows.On theDay*Payment day171525of each and every month commencing onDate* MM slash DD slash YYYY In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account;I / We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you. Health Screening Questionnaire1. Have you ever suffered from any heart, respiratory or metabolic condition?* No, non apply High Cholestrol Stroke Non-Insulin Dependent Diabetes High Blood Pressure Insulin Dependent Diabetes Heart Disease Cancer Other Lung Disease Asthma Peripheral Vascular Disease (Inflammations in the veins) 2. Do you currently experience any symptoms of respiratory or cardiovascular disease?* No, non apply Chest Pain Palpitations Ankle Swelling Intermittent Claudication (Leg cramps during walking) Frequent fainting or Dizzy Spells Shortness of Breath 3. Do you currently experience any general medical symptoms?* No, non apply Flu-like Symptoms Other Significant Symptoms 4. Do you currently suffer from any symptoms of joint injury or joint disease?* Yes No 5. Are you currently pregnant?* Yes No 6. Are you a current smoker or have you smoked within the last 6 months?* Yes No 7. Do you do less than 3 hours of physical activity per week? (Including housework, gardening etc.)* Yes No Terms & ConditionsPaid in Full (PIF): This is a legal contract. You will have access to Explosive Functional Fitness Boot Camp location for the duration of the time stated above. If under contract, you can freeze 1 (one) month per year for any reason. There is a R100.00 freeze fee. PIF agreements cannot be transferred to anyone. Once the paid allotment of time expires in your contract, your membership will continue month to month at the monthly rate of your membership option in the price list above. I understand that cancellation must be done by “cancellation form”. To receive a copy of this, please email eff@explosivefunctionalfitness.com and the cancellation form will be emailed back within 24 hours. No other form of cancellation will be valid or accepted. There are no refunds for PIF. Electronic Fund Transfer (EFT): This is a legal contract. You will be automatically billed each month for the amount specified above for the duration of the program specified above. We have a 30 day money back guarantee from the time of this signing. After this period has elapsed, no refunds under any circumstances. If you are under a monthly agreement, when it expires your membership will continue month to month. If you decide to cancel the 6, 12 or 18 month program before the end date stated above, then you will be charged the R1499.00 cancellation fee unless you have a medical doctor’s note relieving you of the ability to exercise. I understand that cancellation must be done by “cancellation form”. To receive a copy of this, please email eff@explosivefunctionalfitness.com and the cancellation form will be emailed back within 24 hours. No other form of cancellation will be valid or accepted. Declined debit accounts will be subject to R25.00 fee. You cannot be credited a freeze month if you notify us after payment has been drawn for the current month. If under contract, you can freeze 1 month per year for any reason. There is a R100.00 freeze fee. Additionally if you are or become pregnant, you can freeze for the allotted amount of months your doctor specifies with a note from the medical doctor but cannot be backdated. Please note that EFF boot camp closes for two weeks from December 23 till January 9 2017 and debit orders will go off as per normal. If you would like to freeze for that period, please notify us via email and 2 weeks will added to your programme duration at no cost. By ticking the box provided below you agree you have read the terms above and that you fully understand the rules of cancellation for your contract. By ticking the box provided below, I acknowledge that I have read and understood all of the terms and conditions above, and I agree to comply with all of the terms & conditions stated above, and give Explosive Functional Fitness Bootcamp (PTY) Ltd permission to carry out the payment terms above.Indemnity Indemnity Waiver | Terms and Conditions Thank you for investing in Explosive Functional Fitness Boot Camp training; we appreciate your focus and dedication to achieving your goals and look forward to a great training relationship. Please take note of the following terms and conditions that will create the foundation and guidelines for your training time with us. Health Concerns. Prior to, or during the course of your training, health concerns may arise that need further input from your doctor, physiotherapist or other allied health professionals. Your trainer may request your assistance in obtaining that information. If a particular exercise is uncomfortable or painful for you to do or you have an injury, you may stop. Please ensure you have sufficient water during the training sessions. No Liability / Indemnity By ticking this registration form, you have volunteered to participate in a program of physical exercise under the direction of Explosive Functional Fitness Bootcamp (PTY) Ltd and/or its’ staff and/or its Instructors which will include, but may not be limited to, weight and/or resistance training. In consideration with Explosive Functional Fitness Boot Camp’s agreement to instruct, assist, and train you, you hereby and forever release and discharge and hold harmless Explosive Functional Fitness Bootcamp (PTY) Ltd and/or its’ Instructors from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with your participation in this or any exercise program, including any injuries resulting therefrom. You understand and are aware that strength, flexibility and aerobic exercise, including the use of equipment, is a potentially hazardous activity. You also understand that fitness activities involve a risk of injury and even death, and that you are voluntarily participating in these activities and using equipment with knowledge of the dangers involved. You hereby agree to expressly assume and accept any and all risks of injury or death. You further declare that you are physically sound and suffering from no condition that would prevent you from participation or use of equipment. You acknowledge that you have either had a physical examination and have been given Doctors permission to participate, or that you have decided to participate in activity and use equipment without the approval of your Doctor and do hereby assume all responsibility for your participation and activities, and utilisation of equipment in your activities. You are also aware that Explosive Functional Fitness Bootcamp (PTY) Ltd may record workouts for later use on television segments, websites, promotional materials or in any other way they see fit. By signing acceptance of these terms and conditions, you hereby authorize Explosive Functional Fitness Bootcamp (PTY) Ltd to use your name and likeness, voice, verbal statements, video-taped pictures for any of the aforementioned purposes. Right of admission is reserved to EFF bootcamp. YOU ACKNOWLEDGE THAT YOU HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY TICKING ACCEPTANCE OF THIS INDEMNITY / HEALTH SCREENING FORMS, YOU ARE WAIVING ANY RIGHT YOUR SUCCESSORS OR YOU MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST EXPLOSIVE FUNCTIONAL FITNESS BOOTCAMP (PTY) LTD AND/OR ANY OF ITS STAFF AND/OR INSTRUCTORS.MANDATE I / We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been issued by me/us personally. CANCELLATION I / We agree that although this Authority and Mandate may be cancelled by me / us, such cancellation will not cancel the Agreement. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you. ASSIGNMENT I / We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party. * I have read and accept the Terms and Conditions Signed atPlace where signed* Member Signature*NameThis field is for validation purposes and should be left unchanged. Δ