Infinite Youth Qi Gong Association of Australia, Inc
Registered No: A1021014P
(*) required
Person Registration
Personal Details *
First Name *
Middle Name
Last Name *
Date of Birth *
DD / MM / YYYY
Gender *
Male
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Health Condition (Kept private and confidential)
High Cholesterol
Diabetes
Hypertension
Stroke
Cardiovascular condition
Pacemaker
Angina
Osteoporosis
Asthma / Bronchitis
Post-surgery (past 6 months)
Cancer diagnosis
Epilepsy (fits)
Allergy
Others
(Precaution: Participants with any of the above, or other medical conditions should always consult their medical doctor before proceeding to undertake Infinite Qi Gong practice)
Contact Details *
Mobile Number
Home Number
Email Address
Your Location *
Australian Capital Territory
New South Wales
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Emergency Details
Emergency Contact Person
Emergency Mobile Number
Relationship
You will be directed to membership registration page next