Thibodaux Regional Fitness Center: Family

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

$157.80

$310.75

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Family - Standard	$0.00	$143.00	$0.00	0
Family - Standard	$131.60			0
Enrollment Fee	$150.00	$0.00	$0.00	0
Sub-Total	$281.60	$143.00
Tax	$29.15	$14.80
Total	$310.75	$157.80

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

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