MEMBERSHIP CATEGORY NEW
INDIVIDUAL
RE-INSTATE
JOINT
CHANGE OF DETAILS
PRINCIPAL MEMBER SURNAME:
FORENAME:
TITLE:
ADDRESS:
POSTCODE: HOME TELEPHONE:
MOBILE:
DATE OF BIRTH:
EMAIL:
NEXT OF KIN:
CONTACT NUMBER:
SECONDARY MEMBER SURNAME:
FORENAME:
TITLE:
ADDRESS:
POSTCODE: HOME TELEPHONE:
MOBILE:
DATE OF BIRTH:
EMAIL:
NEXT OF KIN:
CONTACT NUMBER:
HOW DID YOU HEAR ABOUT UTOPIA SPA?
IMPORTANT: I declare that the information on the application form is correct at the time of joining. Should any details change I will inform the spa in writing. I declare that I have read and understood the membership agreement and agree to abide by it. I understand that failure to abide by this agreement and the rules and regulations of the spa will result in termination of my membership where no refund will be given.
SIGNED
SIGNED
(PRINCIPAL MEMBER)
(SECONDARY MEMBER)
DATE
DATE
FOR OFFICE USE ONLY DIRECT DEBIT £
FIRST PAYMENT £
DATE
CASH/VISA/MASTERCARD/OTHER
DATE
AUTHORISED
PRINCIPAL MEMBERSHIP NO
SECONDARY MEMBERSHIP NO