MembershipsThrough our membership packages, you will have swipe tag access to the gym floor 15 hours a day, 365 days a year to ensure you have every opportunity to get your workout in.MEMBERSHIP $25 per weekIncludes gym access and unlimited classes.$1300 per year* Min 3 month term Go Platinum Now1 YearGold Membership$15.00 per week$750 in total* Min 12 month term6 MonthSilver Membership$16.00 per week ($38.00 upfront) $405 in total* Min 6 month term3 MonthBronze Membership$16.50 per week ($38.00 upfront) $212 in total* Min 3 month termCasual Use: $10 per visitMembership and Medical Info By submitting this online form you agree that all information given is true and accurate and that should your personal details change you will inform us immediately.Full Name*Age*Date of birth* DD MM YYYYAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Home PhoneMobile Phone*Emergency Contact Person*Emergency Contact Person's Number*Membership Type*Platinum - WeeklyGold - WeeklyGold - MonthlyGold - UpfrontSilver - WeeklySilver - MonthlySilver - UpfrontBronze - WeeklyBronze - MonthlyBronze - UpfrontOnline PTIf paying weekly or monthlyBSBAccount NumberBankCard TypeCard Expiry1. Do you have, or have you had:* Heart Disease High Blood Pressure High Cholesterol Diabetes Lung Disorder )eg. asthma, emphysema) Other Cardiac Problems (incl. pacemaker) None of the abovePlease specify details here2. Have you ever been told you are at risk of...?* Heart Disease High Blood Pressure High Cholesterol Diabetes Stroke None of the abovePlease specify details here3. Have you ever been told that you have heart problems, eg.* Heart Murmus Valve Defect Racing Heart Irregular Beats Angina Other (please specify) None of the abovePlease specify details here4. Do you have, or have you experienced...?* Epilepsy Fainting Seizures Dizzy Spells Convulsions None of the abovePlease specify details here5. Do you experience sudden shortness of breath?* Yes No6. Have you ever had a pain or pressure, either at rest or during exercise?* In the middle of, or on the left side of, the chest In the neck region At the left shoulder or down the left arm None of the abovePlease specify details here7. Do you take any medications for (please specify below)* Heart Disease Diabetes Cholesterol Blood Pressure Asthma or breathing problems None of the abovePlease specify details here8. Are you aged over 60 years of age?* Yes No9. Do you have any joint or muscular problems that may affect your ability to train?* Yes No10. Do you have any other conditions or injuries that may affect your ability to train?* Yes NoPlease specify details hereToday's Date* Date Format: DD slash MM slash YYYY I agree that all information provided above is true and accurate* Yes, I agreeRelease and Waiver of Liability Form (Please Read)Upon checking in at the NICK HOSE FITNESS Residence, all residents are required to sign the Fitness Center Release and Waiver of Liability Form below. Should you have any questions regarding this or any other items, please do not hesitate to contact us. Health Statement: In requesting permission to access or use the equipment of the NICK HOSE FITNESS facility, I affirm that my general health is good and that I am not adversely affected by the exercise I will undertake. I further affirm that I am able to perform exercise of a vigorous nature. I am not currently under the care of a physician who should be advised of my desire to participate in this physical activity. If I am under the care of a physician, I affirmatively state that I have received his/her permission to participate in vigorous exercise at the NICK HOSE FITNESS Center. AGREEMENT TO FOLLOW RULES AND POLICIES: I agree to follow all rules and policies of the NICK HOSE FITNESS facility and to abide by any reasonable request concerning use of the facility directed to me by the staff of NICK HOSE FITNESS. I agree to operate and use the equipment only in the manner in which it was designed and intended to be used. I understand that my failure to abide by and to follow instructions or request may result in the termination of my privileges of using the facility. I further understand that NICK HOSE FITNESS has the right to terminate or alter my privileges at the NICK HOSE FITNESS facility at its complete and unilateral discretion. RELEASE AND WAIVER: In consideration of my access to the NICK HOSE FITNESS facility I hereby accept all risks to my health and of my injury or death that may result from such participation and I hereby release of the Office of NICK HOSE FITNESS and its employees and representatives from any liability to me, my personal representatives, estate, heir, next of kin and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may to result from or occur during my use of the facilities, whether caused by negligence of the company, employees, or representatives or otherwise. I agree to release and hold harmless NICK HOSE FITNESS and its employees from any and all liability whatsoever which may result from my use if the facility or equipment.AGREEMENT TO FOLLOW RULES AND POLICIES AS ABOVE* Yes, I agreeI have carefully read this agreement and understand it to be a release and waver of all claims and causes of action for my injury or death or damage to my property that occurs while using the NICK HOSE FITNESS facility and it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligence or intentional act of omission.CAPTCHA