Membership Interest Registration Form Please complete and submit the following to express your interest in our special foundation membership:
	FIRST NAME:		*
	LAST NAME:		*
	GENDER:	Female Male	*
Contact Information:
Phone Home Mobile :		*
Email Address:		*
Misc. Information:
Exercise History:		Never been a gym member Previously been a gym member Currently a gym member *
Facility Interests:		Health Club Only Pool Only Health Club and Pool
Relevance to QUT (ie. staff or student)?		Student Staff None
Do you work at Kelvin Grove?		YES NO
Are you a local resident?		YES NO
How did you hear about us?		Please Select Door to Door Flyer Mail Out Radio Referral Television Yellow Pages *
Do you authorise us to contact you?		Yes No
* denotes compulsory fields