Strive Health & Fitness: EFT 12 Month Commitment

Primary Member Information

First Name

M.I.

Last Name

Address 1

Address 2

City

State / Province

Zip / Postal Code

Home Phone

Mobile Phone

OK to Contact Home Phone

OK to Contact Mobile Phone

Preferred Phone

Home

Mobile

OK to Contact Email?

Emergency Contact

Name

Phone

Birth Date

Gender

Male Female Other

Add-Ons for this member

Locker rental

$0.00 down $15.00 / month

Monthly 1st Payment

$53.49

$200.53

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Start up/enrollment fee	$149.00	$0.00	$0.00	0
Membership Dues	$0.00	$49.99	$49.99	0
Membership Dues	$38.41			0
Sub-Total	$187.41	$49.99
Tax	$13.12	$3.50
Total	$200.53	$53.49

Payments will then be processed on a Monthly 1st basis there after.

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