Aqualife	Gym	Pool
Monday - Friday	5:30am - 8:30pm	5:30am - 8:30pm
Saturday and Sunday	7am - 5pm	7am - 5pm

Online Form - Rehab Membership Request

Thank you for considering the The Town of Victoria Park as your rehabilitation centre.

Client Name*

Client Date of Birth*

Client Address*

Client Contact Number*

Client Email Address*

Client Emergency Contact Name*

Client Emergency Contact Number*

Insurance Company Name*

Insurance Physical Address*

Insurance Postal Address*

Claim Number*

Case Manager Name (Full name)*

Case Manager Email Address*

Case Manager Phone Number*

Allied Health Provider Name*

Allied Health Provider Address*

Allied Health Provider Email Address*

Allied Health Provider Phone Number*

Type of Membership (please select one)*

Gym & pool 3-month membership $31210x pool plus (hydro) $9710 x standard pool (no hydro) $57

Type the code from the image:

Type the code from the image