Couple Membership -

Application Form - Couple Membership

The below application form is for signing up and a making lump sum payment for a specified length of membership. You will need to have your credit card or PayPal details ready for payment at the end of this form. Please Note: Direct Debit and Easy Pay options are available at reception only at this time.

I wish to apply for membership of the Hibernian Heath & Leisure Centre. I understand that all applications for admission to membership of the club shall be made strictly subject to the Rules of the Club in force at the time. Payment of membership shall constitute an agreement to be bound by the rules.
Personal Details
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region
Date of birth*
Company Name
Mobile Phone*
Home Phone
Email*
Enter Email Confirm Email
Name and contact number of the next of kin*
2nd Member
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region
Email
Date of birth*
Occupation
Home Phone
Mobile Phone
Name and contact number of the next of kin*
Membership Length
It is your responsibility to select the correct membership option. Please call us if you are in any doubt. Deductions will automatically stop at the end of the subscription period.
Total
0,00 €
Name
This field is for validation purposes and should be left unchanged.

Couple Membership

Application Form - Couple Membership

Personal Details

2nd Member