Membership Authorisation Agreement We would love to hear from you! Please fill out this form and we will get in touch with you shortly. Step 1 of 2 - Member Details 0% Name*FirstLastDate of birth* Gender*MaleFemaleAddressStreet AddressAddress Line 2CityZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountryPhone (Home)Mobile phoneEmailOccupationCompanyAre you a student?YesYou will need to provide your student ID number as well as expiry date. Please note: You will also need to bring your student ID for verification on your first visit.Student ID NumberStudent ID expiration dateDeclarationDo you agree to the following terms and conditions?*YesPlease Read Full Terms and Conditions Before clicking YesI declare that: I understand this is a legally binding contract between me and Ludus Magnus Limited I have read and understand the conditions of membership set out above and on the back of this form and agree to be bound by them The details I have provided are true and accurate. I understand that Ludus Magnus Limited will collect my personal information in order to process my membership declaration for account administration and marketing. I have the right to see and ask for correction of any personal information about me Emergency Contact InformationEmergency Contact Name*Emergency Contact Number*Relationship*Employment DetailsOccupationEmployerCardiovascular Risk AssessmentDo you:Have a history of heart disease*YesNohave a family history of heart disease*YesNohave high cholesterol*YesNohave high blood pressure*YesNohave diabetes*YesNosmoke cigarettes*YesNoOther ConditionsDo you have:epilepsy or seizures*YesNorecent surgery (past 6 months)*YesNobreathing or lung problems (asthma/COPD)*YesNorecently released from physical therapy (reason)*YesNorecent or present hernia*YesNorecently (past 6 months) or presently pregnant*YesNoexperience dizziness, shortness of breath, or ataxia, with exercise*YesNoany other limitations (please list if yes)*YesNoPlease list your limitationsPlease list all medications/supplements that you are currently taking:Waiver and ReleaseYou (the client) agree that if you engage in any physical exercise, class, or activity, you do so at your own risk. You agree that you are voluntarily participating in activities and assume all risk of injury or illness. You agree to release and discharge LUDUS MAGNUS LTD from any and all claims or causes of action (known or unknown) arising out of LUDUS MAGNUS LTD’S negligence. You acknowledge that you have carefully read this Waiver and Release and fully understand that it is a release of liability. You are waiving any right that you may have to bring a legal action to assert a claim against LUDUS MAGNUS LTD for its negligence. By submitting this form you have agreed to the above