YMCA Sports Centre Membership Registration Step 1 of 4 25% Membership InformationMembership Type(Required)AdultYouth/Student (under 18s or Valid NUS card)Concession (over 60/in receipt of benefits)Salutation(Required)MrMrsMissMasterDrOtherName(Required) First Last Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required) Male Female Car Registration Number Member ID PhotoMax. file size: 1 GB. There should only be 1 face in the photo The face is not too small compared to the image dimensions The face is not blurry The image is not too dark The face has a neutral pose It is a recent photo No hat, no sunglasses Full-on front face view, no profile views Contact InformationEmail Address(Required) Address(Required) Street Address Town/City Post Code Preferred Contact Number(Required)Emergency Contact (Next of Kin)Please provide details of the person you would like us to contact in case of emergency. Emergency Contact Name(Required) Emergency Contact Number(Required)Privacy PolicyConsent(Required)The information you enter into this form will be collected and stored by YMCA Cheltenham. Please tick the box below to confirm you understand. I agree to the privacy policy.(Required)We will never share your personal details with anyone else and we will always store your personal details securely. We will only use them to provide the service(s) that you have requested and to communicate with you in the ways you have agreed to. For full details see our privacy policy. Physical Activity Readiness QuestionnaireHas your doctor ever told you that you have a heart condition?(Required) Yes No Do you suffer from shortness of breath or chest pain when partaking in physical activity?(Required) Yes No Do you have Diabetes or Epilepsy?:(Required) Yes No Do you suffer from dizziness or fainting?(Required) Yes No Do you have arthritis or bone/joint problem that could be made worse by exercise?(Required) Yes No Do you suffer from asthma?(Required) Yes No Are you pregnant or have recently given birth?(Required) Yes No Have you ever been told to only exercise under the recommendation of a doctor?(Required) Yes No Do you suffer from back pain?(Required) Yes No Do you smoke?(Required) Yes No Do you exercise regularly?(Required) Yes No Are you currently taking any prescription medications?(Required) Yes No Please provide details of the prescription medication you are currently takingAssumption of Risk(Required)"I hereby state that I wish to participate in activities which include, but are not limited to, aerobics, cycling, running and gymnasium exercise (aerobic and resistance) and stretching exercise. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me. I have had the opportunity to ask questions prior to exercising and they have been answered to my satisfaction." I agree Member's DeclarationMember's Declaration(Required)"I agree to abide by the conditions of membership as laid down by the Board of Directors, and its appointed officers, and I accept that these may be changed from time to time. I agree that this information is being held on a computer system for use in accordance with the provision of the Data Protection Act. I have read and agreed to the statement titled Assumption of Risk. I have completed the Physical Activity Readiness Questionnaire before participating in an physical activity. In the event of an accident or illness, I give my permission for YMCA staff or volunteers to provide emergency first aid should the need arise." I agree(Required)Date Day Month Year Untitled Untitled
