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

$118.13

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	$10.40			0
Sub-Total	$110.40	$79.00
Tax	$7.73	$5.53
Total	$118.13	$84.53

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

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