Mokoia Recreation Centre Membership Application Form

This form is step 1 of two steps in the join-up process. Once you've completed the form we'll see you at the Centre to get your membership card and start your workouts! 

Privacy: The information we collect in this form is for your safety, and for the safety of others. It may be used in the event you have an accident, suffer a medical emergency, or cause injury or loss to someone else or to property. Toi Ohomai collects and holds all information strictly in accordance with the Privacy Act 2020. In addition to the information collected in this form, CCTV may be operating in or around these premises.
 
How did you hear about this gym?
Gender
Are you happy to receive text messages from us?
Emergency Details
Medical/Health Details
Does/has anyone in your family under 60 suffer(ed) heart disease, stroke, raised cholesterol or sudden death?
Do you have a heart condition?
Are you a male over 35, or female over 45, and not used to regular exercise?
Have you been hospitalised recently?
Are you pregnant?
Do you have a heart murmur?
Do you have high blood pressure (greater than 149/90)
Do you/have you experience(d) palpitations or pain in the chest?
Do you have raised cholesterol/triglycerides?
Do you have/have you had gout, stroke, diabetes, epilepsy, hernia, or glandular fever?
Do you have/have you had rheumatic fever, dizziness, or fainting?
Do you have/have you had a liver or kidney condition?
Do you have/have you had a stomach or duodenal ulcer?
Do you have/have you had arthritis, asthma, cramps, muscular pain?
Do you smoke?
Are you dieting or fasting?

Important: If you have ticked YES to any of the above medical conditions or health information OR if you are unsure, we recommend you see a doctor and obtain a medical certificate for the exercise regime you wish to carry out.

Exercise and Fitness Background
How is your nutrition at the moment?
How would you describe your current physical condition?
What are your main goals for exercise? (choose two only)
On a scale of 1 to 10, how confident do you feel coming into the gym (1 being not very, 10 being super confident)
On a scale of 1 to 10, how confident do you feel coming into group fitness classes? (1 being not very, 10 being super confident)
In submitting this application you agree to our Terms and Conditions.

Contact Information

Mokoia Recreation Centre

07 346 8630

Monday-Thursday, 5.30am-8.00pm

Friday, 5.30am-7.00pm

Saturday-Sunday, 7.00am-12.00pm

Mokoia Campus