Gymnasium Kimbulawala

Family / Spouse Infomation

Relationship Type *

Title *

Full Name: *

Gender:
Male Female

Email: (Please enter a valid email address.) *

Permanent Address: *

Date of Birth (YYYY-MM-DD): *

Occupation:

Member Type *

NIC/ Passport No/ Driving Licence No *

NIC: *

Passport No *

Driving Licence No *

Member ID (Enter your Member ID): *

Reason for Joining this Gym:

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Family / Spouse Medical Infomation

Advice from physician whether to exercise or not
Yes No

If you have suffered any of following conditions, please submits report/letter from your doctor (Information is needed prior to training)

Heart Attack / Stroke
Yes No

Diabetes
Yes No

High Blood Pressure
Yes No

Hernia
Yes No

Pain or Tightness in the chest
Yes No

Asthma
Yes No

High Cholesterol
Yes No

Fainting Attacks
Yes No

Stomach or Duodenal Ulcer
Yes No

Back Problems
Yes No

Liver of Kidney Condition
Yes No

Epilepsy or Fits
Yes No

Difficulty in breathing or Chronic cough
Yes No

Additional Medical Notes

Family / Spouse Contact Infomation

Telephone - Mobile: *

Telephone - Home: *

Emergency Contact Person:*

Emergency Contact Person Contact No:*

Emergency Contact Person Address *

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Membership Registration for the Kimbulawela Gymnasium

Fill in the following form and submit your details

Membership Infomation

Personal Infomation

Medical Infomation

If you have suffered any of following conditions, please submits report/letter from your doctor (Information is needed prior to training)

Contact Infomation

Family / Spouse Infomation

Family / Spouse Medical Infomation

If you have suffered any of following conditions, please submits report/letter from your doctor (Information is needed prior to training)

Family / Spouse Contact Infomation

User Details Confirmation

Membership Infomation

Member Type :

Membership Type :

Duration :

Amount :

Personal Infomation

Title :

Full Name :

Gender :

Email :

Permenant Address :

Date of Birth :

Occupation :

NIC/ Passport No/ Driving Licence No :

Reason :

Medical Infomation

Advice from physician whether to exercise or not :

Heart Attack / Stroke :

Diabetes :

High Blood Pressure :

Hernia :

Pain or Tightness in the chest :

Asthma :

High Cholesterol :

Fainting Attacks :

Stomach or Duodenal Ulcer :

Back Problems :

Liver of Kidney Condition :

Epilepsy or Fits :

Difficulty in breathing or Chronic cough :

Additional Medical Notes :

Contact Infomation

Telephone - Mobile :

Telephone - Home :

Emergency Contact Person :

Emergency Contact Person Contact No :

Emergency Contact Person Address :

Family / Spouse Infomation

Payment Infomation

Category :

Membership Type :

Duration :

Amount :

Convenient_fee :

Total amount :

Payment Option *

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I hereby certify that the above information declared is true and correct to the best of my knowledge.

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