Ripon Wellness Center: Senior 3 Month

This plan requires 1 member with a maximum of 10 members.

How many total members would you like on this plan?

* This plan requires a minimum number of members including the primary member.

(1) Primary Member Information

First Name

M.I.

Last Name

Address 1

Address 2

City

State / Province

Zip / Postal Code

Home Phone

Mobile Phone

OK to Contact Home Phone

OK to Contact Mobile Phone

Preferred Phone

Home

Mobile

OK to Contact Email?

Birth Date

Gender

Male Female Other

$35.00

$39.95

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Joiner Fee	$25.00	$0.00	$0.00	0
Ripon Wellness Center	$0.00	$35.00	$35.00	0
Prorated Dues	$14.95			0
Sub-Total	$39.95	$35.00
Tax	$0.00	$0.00
Total	$39.95	$35.00

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

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