Top Gun, 1 on 1 Private Session, Month to Month Membership

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Name *

First

Last

Date of Birth

ID Number

Email *

The Agreement Reference Number will be emailed to this email address.

Phone

Start Date

Emergency Contact Person *

First

Last

Emergency Contact Person's Number

illnesses, Alternative month?

Alternative Emergency Contact Number if available

Relationship to Emergency Contact Person

Would you like the Top Gun, 1 on 1 Private Session, Month to Month Membership at R2000 per month? *

*1 Private session per week *

Which of these conditions or diseases have you ever suffered from any?

Stroke
High Cholesterol
Intermittent Claudication (leg cramps)
High Blood Pressure
Diabetes
Shortness of breath
Heart Disease
Cancer
Chest pain
Lung Disease
Asthma
Ankle swelling
Peripheral Vascular Disease
Palpitations
Frequent fainting or dizzy spells
Other

What is the conditions or diseases that you have suffered from?

Given by (Name of Bank Account Holder):

Top Gun Boxing Gym (Pty) Ltd _ Authority/Mandate: Paper/Electronic

Physical Address:

Bank Name:

Branch Name / Branch Code

Account Number

Type of Account

Current (cheque)
Savings
Transmission

Date

Contact Number

Amount

Name of Beneficiary

Address

Abbreviated Short name to be used:

TOPGUNBOX

Netcash Authorisation *

I/We hereby authorise Netcash (Pty) Ltd to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned bank on condition that the sum of such payment instructions will not differ from my/our obligations as agreed to in the Contract Reference Number. The individual payment instructions so authorised must be issued and delivered on the date when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not differ as agreed to in terms of the Agreement. The payment instructions so authorised to be issued must carry the Contract Reference Number, included in the said payment instructions, and must be provided to identify the specific contract. The said Contract Reference Number should be added to this form in section E before the issuing of any payment instruction and communicated directly after having been completed.

I /we agree that the first payment instruction will be issued and delivered on

After the first payment instruction has been issued and delivered, we authorise thereafter, monthly debit orders on the selected day below:

Select checkbox to agree alternate debit day when needed. *

I agree to that, if however, the date of the payment instruction falls on a non-processing day (weekend or public holiday) I agree that the payment instruction may be debited against my account on the following business day; or Subsequent payment instructions will continue to be delivered in terms of this authority until the obligations in terms of the Agreement have been paid or until this authority is cancelled by me/us by giving you notice in writing of not less than the interval (as indicated in the previous clause) and sent by prepaid registered post or delivered to your address indicated above.

Select checkbox to ensure fund availability *

I undertake to ensure that funds will be available and authorise TopGunBox to re-submit the debit and/or implement tracking on this account and collect funds as soon as they are available if the debit is unsuccessful. I acknowledge that the bank may charge additional fees for resubmission or failed transaction or disputed transactions, and TopBunBox may recover such fees from me which may amount from a minimum of R50.00 (Fifty Rand). I acknowledge that I am not entitled to any refund while this authority is in force, if such amounts were legally owing to TopGunBox I authorise TopGunBox to disclose to any credit bureau any information concerning this credit profile and payment history.

Select checkbox to agree to the Mandate *

I/we acknowledge that all payment instructions issued by you will be treated by my/our abovementioned bank as if the instructions had been issued by me/ us personally.

Select checkbox to agree to our Cancellation Policy *

Missed classes cannot be made up or carried over into another month and this agreement cannot be suspended for any period of time unless due to exceptional circumstances such as serious injury ill health. In such circumstances, TopGunBox may at its sole discretion, agree to to pause this agreement for up to a maximum of three months (such medical evidence in support thereof to be provided by myself). Thereafter, ordinary membership fees shall apply. This Agreement cannot be put on hold over or due to holiday periods, including but not limited to religious and/or student holidays. I/we agree that although this authority and mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/we also understand that I/we cannot reclaim amounts, which have been withdrawn from my/our account (paid) in terms of this authority and mandate if such amounts were legally owing to you, unless paid for upfront by cash or card I /we agree to be liable to pay the pro-rated amount for the remaining months of the contract, as stipulated in the terms of the agreement I /we signed. This means that members will be required to pay for all remaining months based on the contract’s original duration, which amount/s shall become due and payable immediately All Top Gun Boxing gym members are required to provide a minimum of one month's notice before cancelation of contract. Upon receiving the notice, a pro-rated cancellation fee will be applied based on the remaining term of the contract. Notwithstanding the above, TopGunBox may terminate my membership and/or this Agreement at the end of any given month for any reason whatsoever, and may suspend my membership and access to their facilities with immediate effect prior to such termination for any reason whatsoever. In such circumstances, TopGunBox will refund a pro rate portion of any fees paid for the applicable month.

Select checkbox to agree to our Liability Policy *

I agree that TopGunbox, it’s directors, employees, representatives, and/or agents shall not be liable for any personal injuries, damage or loss of personal property for any reason whatsoever. I agree and understand that notwithstanding any consultation on exercise programs, methods and/or types of equipment, which may be provided by TOpGunBox and/or it’s employees and/or agents (“the services”) , my selection and/or use of such exercise programs, methods and/or types of equipment shall be my sole responsibility and TopGunBox, it’s directors, employees, representative and/or agents shall not be liable to myself or any third party for any claims, demands, injuries, damages or actions arising due to unjury to me and/or any third person or property for any reason whatsoever, arising out of or in connection with the use of the services, equipment and/or facilities of TopGunBox or the premises where TopGun Box is located. By signature of this Agreement by myself and/or my legal guardian and/or primary care giver duly authorized, I release and discharge TopGunBox, its successors, assigns, officers, directors, employes, representatives and agents from all claims demands, injuries, damages, actions, losses and expenses. I agree that this section and all of its provisions will survive any cancellation of this agreement. I also agree that the provisions of this Agreement shall be deemed severable and the invalidity or unenforceability of any provision of this Agreement shall not affect the validity or unenforceability of any of the other/remaining provisions of same.

Declaration of Health: List all your health conditions, illnesses, issues, and injuries:

I undertake to ensure that I consult a medical doctor if necessary prior to participating in any form of exercise at TopGunBox and that I disclose in this Agreement all my history or illness, injuries, or other health related issues in cases of emergency, including but not limited to asthma, epilepsy and heart conditions.

Select checkbox to acknowledge the Assignment *

I/We acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party.

Select checkbox to confirm the Acceptance *

I confirm that I have read and understand the terms and conditions of this Agreement and agree to all the terms and conditions stipulated herein, including but not limited to the payment structure, waiver and release of liability, and signed this Agreement with full knowledge of its content. I further confirm that all details provided by me are accurate and that I have consulted with my physician or doctor prior to commencing training.

Signature

Clear Signature

Signature as used for operating on the account

Clear Signature

Member signature and/or Parent and/or Guardian if Member is under the age of 18 years old