Welcome to the online sign up for Carlson Gracie Surrey.

 

Thank you for joining and we look forward to having you as a member of our team.

 

If you are under 18 years old your parent or guardian must complete the membership on your behalf (please insert Child’s name in the Unique Ref Field).

 

Carlson Gracie Surrey Terms and Conditions External Link I have read and agree to the Terms & Conditions. *
Unique Reference No If you have a Unique Reference No, please enter it here:

Please Select your Membership Plan Click Here for More Information
Adults - 1 Year Contract - £75.00 p/m
Plus a Pro-Rata payment and a £30.00 Joining Fee payable on first visit
Adults - 3 Month Contract - £85.00 p/m
Plus a Pro-Rata payment and a £30.00 Joining Fee payable on first visit
Juniors (Under 14 years old) - 1 Year Contract - £25.00 p/m
Plus a Pro-Rata payment and a £15.00 Joining Fee payable on first visit
Juniors (Under 14 years old) - 3 Month Contract - £30.00 p/m
Plus a Pro-Rata payment and a £15.00 Joining Fee payable on first visit
Students in Full Time Education - 1 Year Contract - £50.00 p/m
Plus a Pro-Rata payment and a £20.00 Joining Fee payable on first visit
Students in Full Time Education - 3 Month Contract - £60.00 p/m
Plus a Pro-Rata payment and a £20.00 Joining Fee payable on first visit
Direct Debit Payment Date

Your chosen agreement is between yourself and the above mentioned Company, Debit Finance Collections plc is purely the collecting agent working on behalf of the above mentioned Company.


Personal Details Click Here for More Information
Title *
First Name *
Last Name *
Date of Birth *




Address & Contact Details Click Here for More Information
House Name/Number *
Postcode *
Telephone *
Mobile Phone *
(if not available please repeat first telephone number here)
E-mail * Click Here for More Information
Confirm E-mail *


PHYSICAL ACTIVITY READINESS QUESTIONNAIRE


Please read all questions carefully and answer honestly and provide any further information as necessary

 

  1. Have you ever been told by a medical professional that you have a heart condition? Yes   No
  2. Have you ever had chest pains whilst doing physical activity?Yes   No
  3. Have you ever had chest pains whilst you were resting?Yes   No
  4. Have you ever been told by a medical professional that your blood pressure was too high?Yes   No
  5. Has a medical professional ever advised you against exercise due to injury/illness?Yes   No
  6. Do you suffer from any bone or joint problems?Yes   No
  7. In the past year have you had any major illness or major surgery?Yes   No
  8. Have you ever been diagnosed with diabetes?Yes   No
  9. Have you ever been diagnosed with epilepsy?Yes   No
  10. Have you ever been diagnosed with hepatitis?Yes   No
  11. Have you ever been diagnosed with HIV?Yes   No
  12. Are you currently taking any medication?Yes   No
  13. Are you pregnant?Yes   No
  14. Have you recently had a baby (Within the last 6 weeks?)Yes   No
  15. Do you ever lose your balance because of dizziness or lose consciousness?Yes   No
  16. Do you have any other medical conditions not mentioned above that may interfere with you training a physical sport or create any health risks for you or others who are in close contact with you?Yes   No

PLEASE NOTE THAT IT IS YOUR RESPONSIBILITY TO INFORM THE INSTRUCTOR OF ANY MEDICAL CONDITION THAT MAY AFFECT YOUR HEALTH OR THE HEALTH OF OTHERS WHILST PARTICIPATING IN PHYSICAL ACTIVITY AS THE INFORMATION DECLARED ON THIS FORM IS NOT PASSED ON TO ANYONE.


I confirm that the information I have provided is true, to the best of my knowledge.

Bank Details Click Here for More Information
Account Holders Name *
Bank Account Number *
Bank Sort Code * - -
Please confirm you are the account holder and you are the only person required to authorise direct debits from this account. However if you're not the account holder please do not tick the box and click Next and you will be given the option to print a Paper DDI. *

Customer Name
Date of Birth 01/01/1970
Address
Telephone
Mobile Phone
E-mail
Promo Code
Unique Reference No
Bank Account Name
Bank Account Number
Bank Sort Code --
Chosen Plan
Minimum Term Month (Non Cancellable in this period)

First Direct Debit on 01/01/1970
First Full Payment £0.00
First Direct Debit Total £0.00

The name that will appear on your bank statement will be Debit Finance Collections plc

Collecting Agent: Debit Finance Collections Plc, PO Box 6046, Milton Keynes MK1 9BA Telephone:

E-mail: [email protected] (All enquiries concerning payments should be made to this address)

Company Registration No. 3422873




Direct Debit Instruction

Debit Finance Debit Finance Collections plc
16 Davy Avenue, Knowlhill,
Milton Keynes, MK5 8PL


Direct Debit
Instruction to your
Bank or Building Society
to pay by Direct Debit
Name(s) of Account Holders(s)
Bank/Building Society account number
Branch Sort Code
--
Name and full address of your Bank or Building Society
To The Manager       Bank/Building Society


Address
Postcode
Service User Number
406492
Reference
7131
Instruction to your Bank or Building Society
Please pay Debit Finance Collections plc Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with Debit Finance Collections plc and, if so, details will be passed electronically to my Bank/Building Society.


Date


20/09/2017
Banks and Building Societies may not accept Direct Debit Instructions for some types of account

Direct Debit

The Direct Debit Guarantee


  • This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.

  • If there are any changes to the amount, date or frequency of your Direct Debit, Debit Finance Collections plc will notify you 5 working days in advance of your account being debited or as otherwise agreed. If you request Debit Finance Collections plc to collect a payment, confirmation of the amount and date will be given to you at the time of the request.

  • If an error is made in the payment of your Direct Debit, by Debit Finance Collections plc or your bank or building society you are entitled to a full and immediate refund of the amount paid from your bank or building society.

    - If you receive a refund you are not entitled to, you must pay it back when Debit Finance Collections plc asks you to.

  • You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.


Please Print Off and retain for your records.

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