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

$104.83

$172.32

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Couple - Standard	$0.00	$95.00	$0.00	0
Couple - Standard	$56.16			0
Enrollment Fee	$100.00	$0.00	$0.00	0
Sub-Total	$156.16	$95.00
Tax	$16.16	$9.83
Total	$172.32	$104.83

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

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