Mount Carmel Fitness Center: Senior Membership

This plan requires 1 member with a maximum of 3 members.

How many total members would you like on this plan?

* This plan requires a minimum number of members including the primary member.

(1) Primary Member Information

First Name

M.I.

Last Name

Address 1

Address 2

City

State / Province

Zip / Postal Code

Home Phone

OK to Contact Home Phone

Preferred Phone

Home

OK to Contact Email?

Emergency Contact

Name

Phone

Birth Date

Gender

Male Female Other

Source

$84.53

$154.29

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Enrollment Fee	$100.00	$0.00	$0.00	0
Member Senior - Joined Online	$0.00	$79.00	$0.00	0
Member Senior - Joined Online	$44.20			0
Sub-Total	$144.20	$79.00
Tax	$10.09	$5.53
Total	$154.29	$84.53

Payments will then be processed on a Monthly 5th basis there after.

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