Thibodaux Regional Fitness Center: Couple

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

Monthly 5th Payment

$115.87

$213.14

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Couple - Standard	$0.00	$105.00	$0.00	0
Couple - Standard	$93.15			0
Enrollment Fee	$100.00	$0.00	$0.00	0
Sub-Total	$193.15	$105.00
Tax	$19.99	$10.87
Total	$213.14	$115.87

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

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