Insurance membership request form

Please complete all the details below for your insurance membership request and allow up to seven business days for your request to be processed.

Physiotherapists, case workers or support officers who will be accompanying clients to the Centre as part of any rehabilitation/insurance program will be required to complete a Craigie Leisure Centre induction prior to their initial visit.

Please enter your contact information

Please enter the contact's name.
Please enter the organisation's name.
Please enter the contact's phone number.
Please enter the contact's email address.

Member details

Please enter the member's first name.
Please enter the member's last name.
Please enter the member's address.
Please enter the member's suburb.
Please enter the member's postcode.
Please enter the member's phone number.
Please enter the member's email address.
Please select the member's date of birth.

Emergency Contact

Please enter the emergency contact first name.
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Select your membership option

Please select an option.

Invoicing details

Please enter the organisation's name.
Please enter the invoicing contact's name.
Please enter the invoicing address.
Please enter the invoicing suburb.
Please enter the invoicing postcode.
Please enter the invoicing phone number.
Please enter the invoicing email address.
Please enter your claim number.

Membership start date

Please select the start date

Supporting Documentation

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Additional comments

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