Thibodaux Regional Fitness Center: Senior Individual

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

$68.42

$115.96

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Senior Individual - Standard	$0.00	$62.00	$0.00	0
Senior Individual - Standard	$55.08			0
Enrollment Fee	$50.00	$0.00	$0.00	0
Sub-Total	$105.08	$62.00
Tax	$10.88	$6.42
Total	$115.96	$68.42

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

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