Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

DOB *

MM

DD

YYYY

Assess your health needs by checking the box if 'Yes'

History - Have you ever had?

A heart attack or stroke

Heart surgery

Symptoms - Do you experience or have you experienced?:

Chest discomfort with exertion

Unreasonable breathlessness

Dizziness, fainting, blackouts

Are you?:

A Smoker?

Do you have?:

High/Low Blood Pressure

A Diabetic

Asthma

Hernias

Mental health problems or phobias

Please Select One *

A direct debit form must be filled out prior to commencing training with The Project.

Fixed Term - $59pw - 3 Month Minimum Term + $1.75 Admin Fee

Non-Fixed Term - $75pw - No Minimum Term + $1.75 Admin Fee

Name *

First Name

Last Name