Mercy Health & Fitness Center: Individual Membership

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

Add-Ons for this member

Guest Pass Comp. (New Mbrshp)

$0.00 down $0.00 / month

Monthly 5th Payment

$80.00

$138.12

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Standard Mbrshp-Primary	$0.00	$80.00	$0.00	0
Standard Mbrshp-Primary	$63.12			0
Enrollment Fee	$75.00	$0.00	$0.00	0
Sub-Total	$138.12	$80.00
Tax	$0.00	$0.00
Total	$138.12	$80.00

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

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