Common Contracts
1 similar Registration Form contracts
ContractRegistration Form • January 28th, 2009
ELIXR TEEN FIT PROGRAM REGISTRATION FORM The program set out in this agreement is between the student or parent/guardian if student is under the age of eighteen years (identified on the front of this agreement) and Elixr Health Clubs (Elixr) situated on the premises stated above. Elixr Health Clubs is the trading name of Elixr Easts Holdings P/L - ABN: 84 111 634 747 Student Name: First Name: Surname: Address: Street:Suburb: State: Postcode: Date of Birth: Age: Sex: Height(cm):Student Asthma Bronchitis Autism SPD Motor Sensory Disorder Epilepsy Medical ClearanceMedical History: Diabetes Heart Disease ADHD APD Behavioural Condition Other: Parent / First Name: Surname:Guardian :Details Contact Number: Email: Emergency: Contact Name: Contact Number: Member of Elixr: Yes No Member Tag Number: Member Full Name: PRE-EXERCISE QUESTIONNAIREThis section is to be completed by a parent/guardian who is responsible for the medical care of the young person. Does your child have, or previously had:
