Pinehurst FirstHealth Fitness: *Monthly Draft

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

Monthly Payment

$67.00

$57.20

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Monthly Membership	$0.00	$67.00	$67.00	0
Monthly Membership	$57.20			0
Sub-Total	$57.20	$67.00
Tax	$0	$0
Total	$57.20	$67.00

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

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