COUPLE REGISTRATION FORM
Primary Member Details
Full Name
(Required)
First
Last
NIC
(Required)
Gender
(Required)
Male
Female
Your Address
(Required)
Address
City
Date of Birth
(Required)
MM slash DD slash YYYY
Your Phone
(Required)
Email
Emergency Contact Number
(Required)
Emergency Contact Name and Relationship
(Required)
Height (cm)
(Required)
Please enter a number from
5
to
250
.
Weight (Kg)
(Required)
Please enter a number from
5
to
500
.
Medical History/Pre-Existing Conditions:
Chronic Medical Conditions
(Required)
Asthma
Diabetes
Heart Disease
None
Other (please specify)
Specify Chronic Medical Conditions
Allergies
(Required)
Food Allergies
Diabetes
Heart Disease
None
Other (please specify)
Specify Allergies
Previous Injuries or Surgeries
(Required)
Yes (specify)
No
Specify Previous Injuries or Surgeries
Current Medications
(Required)
Yes (specify)
No
Specify Current Medications
Any other medical conditions, restrictions, or limitations recommended by a healthcare professional: (yes [Specify]/no)
Secondary Member Details
Full Name
(Required)
First
Last
NIC
(Required)
Gender
Male
Female
Your Address
(Required)
Address
City
Date of Birth
(Required)
MM slash DD slash YYYY
Email
Your Phone
(Required)
Emergency Contact Name and Relationship
(Required)
Emergency Contact Number
(Required)
Height (cm)
(Required)
Please enter a number from
5
to
250
.
Weight (Kg)
(Required)
Please enter a number from
5
to
500
.
Medical History/Pre-Existing Conditions:
Chronic Medical Conditions
(Required)
Asthma
Diabetes
Heart Disease
None
Other (please specify)
Specify Chronic Medical Condition
Allergies
(Required)
Food Allergies
Diabetes
Heart Disease
None
Other (please specify)
Specify Allergies
Previous Injuries or Surgeries
(Required)
Yes (specify)
No
Specify Injuries or Surgeries
Current Medications
(Required)
Yes (specify)
No
Specify Current Medication
Any other medical conditions, restrictions, or limitations recommended by a healthcare professional: (yes [Specify] / no)
Membership Type
(Required)
Month
Monthly with a Personal Trainer
Six Month
Annual
Total
Untitled
Name
This field is for validation purposes and should be left unchanged.
Δ
Facebook
Instagram
Get In Touch
Call Us
+94 77 007 0101 +94 71 733 1255
Meet Us
Kandy Sports Club, Nittawela.
Email Us
staff@xfitnesskandy.com
© 2024 Design Talk by
Deeptha
. All rights reserved.
