Peggy & Philip B. Crosby Wellness Center: Standard 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

Monthly Payment

$76.68

$130.53

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Enrollment Fee	$75.00	$0.00	$0.00	0
Member Standard - Joined Online	$0.00	$72.00	$0.00	0
Member Standard - Joined Online	$52.14			0
Sub-Total	$127.14	$72.00
Tax	$3.39	$4.68
Total	$130.53	$76.68

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

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