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

$141.25

$249.15

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Family - Standard	$0.00	$128.00	$0.00	0
Family - Standard	$75.78			0
Enrollment Fee	$150.00	$0.00	$0.00	0
Sub-Total	$225.78	$128.00
Tax	$23.37	$13.25
Total	$249.15	$141.25

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

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