Sign up - Rogue MMA | Port Macquarie, NSW

Personal Details

* Required field

Visitor Member

* First name

Last name

* Phone Number Add secondary Phone +

Secondary Phone

* Email Address

Add secondary Email +

Secondary Email Address

* Date of birth

* Guardian First Name

* Guardian Last Name

Pick a check-in code (4 digits)

Address

Street address

City

Zip / Postal code

State

Country

Emergency Contacts

* Required field

* Contact Name

* Phone Number

Relation

Additional Contact

Photo

Capture from camera No camera found. Please connect a camera to use this feature. Upload or use camera Upload photo

Membership

Select
Day Pass

Duration 1 day

Access 1 days

Cost $20.00
Programs All Programs
Select
Month Pass

Duration 1 month

Access 30 days

Cost $150.00
Programs All Programs
Select
Week Pass

Duration 1 week

Access 7 days

Cost $45.00
Programs All Programs

Membership Documents

Waiver / liability release

PLEASE READ & SIGN BEFORE COMMENCING TRAINING

Please ensure you have selected "visitor" at the top of this page before continuing!

All information is held in confidence under National Privacy and Confidentiality laws and will not be given to outside personnel unless subpoenaed by a court of law.

At Rogue MMA PMQ physical contact will be used by the instructor/s, guest instructors and other students. Physical contact is customary or required to learn the techniques under supervision of the instructor/s or guest instructors and will be done so in the safest possible manner. Protective equipment does NOT eliminate the possibility of injury. Rogue MMA PMQ is a FULL CONTACT martial arts gym. Injuries, paralysis, or death can occur. By signing this agreement, you agree to the recognition and acknowledgement of risks involved with training martial arts and waive all liability from Rogue MMA PMQ whether physical injury, paralysis or death, property damage or loss occurs

In the event of injury or emergency you consent to Rogue MMA PMQ notifying emergency services and providing first aid if required.

I consent to photographs, audio or video recording of me whist at Rogue MMA PMQ and usage for advertising purposes or on the internet. I waive all rights to compensation for the usage of these materials.

All information I have provided is true and correct at time of completion and should there be any changes in the future I will notify Rogue MMA PMQ staff on awareness.

Done Clear Sign Below:

Signature

Medical Conditions

Known Medical Conditions

How did you hear about us?

Who referred the member to us?

More details:

Interface Language

Account Password

Please pick a password to log-in to your account later.

Password (minimum 8 characters)

Confirm Password

Payment

Select membership first

Payment Method
Pay Later

Name on card

Payment Card

Payment will be provided later.