Membership Application GLC

The City of Busselton collects personal information to process this form and provide the requested services. Information may be used for related City business purposes or disclosed where authorised by law. To learn how your personal information is handled, access the City’s Privacy Statement or contact the Privacy Officer at privacy@busselton.wa.gov.au.

Gender
This agreement is subject to a 7 day cooling off period. Cancellation of this membership agreement within the time frame specified must be received in writing. A $29 administration fee is applicable to all cancellations.
*This field is required.
DECLARATION:
I declare that I am in a good state of health and fitness and that there is no medical reason whatsoever that could be regarded as a restriction on or an impediment to my application for membership. I acknowledge that during such times I am on the premises (or its surrounds) both my property and my person shall be at my own risk and I will not hold the City of Busselton (or its employees) liable for any personal injury or loss of property however caused. If I am under 16 years of age, I agree that conditions will be placed on my membership and I shall abide by the said conditions.
I acknowledge that the services and programs offered may vary from time to time and be disrupted as a result of maintenance or unforeseen events. In the instance where these events are less than seven consecutive days, I do not have a claim to be reimbursed for the lost time or services during these events.
I acknowledge that this is a binding legal agreement and shall not be cancelled by me. I acknowledge that the agreement may not be transferred to any other person without the consent of the City of Busselton.*This field is required.
This is an ongoing membership agreement. The agreement will continue until either you or the supplier terminates it in the way described in the agreement. If an automatic debit arrangement is in place, membership fees will continue to be debited from your credit card or account until you or your fitness centre cancels the arrangement by notifying your bank or credit provider. If you terminate the agreement or stop the automatic debit arrangement in a manner not described in the agreement, then you may be liable to the Leisure Centre for breach of contract.*This field is required.
Membership Holds:
Memberships may be placed on hold for minimum of TWO weeks and a maximum of THREE months within a 12 month period. You are required to complete a deferral form in advance before the requested time period.*This field is required.
Membership Cancellations:
All cancellations must be received in writing. Confirmation of cancellation will be acknowledged by return email.*This field is required.
Promotional material
Photos used for promotional purposes
If under the age of 18 years, parent/guardian must authorise*This field is required.
Terms & Conditions

Please view our Term & Conditions

Pre-exercise Questionaire

Please complete your Pre-exercise Questionnaire and submit before completing your membership application.

Membership Type Required*This field is required.
Duration*This field is required.
Concession Applicable
Get Audio Code