Summit Health and Fitness: Short-Term Family 3 Month

This plan requires 2 members with a maximum of 5 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

OK to Contact Home Phone

Preferred Phone

Home

Birth Date

Gender

Male Female Other

Add-Ons for this member

Child Care

$30.00 down $0.00 / month

Additional Child

$30.00 down $0.00 / month

$270.00

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Membership Dues	$270.00	$0	$0.00	0
Sub-Total	$270.00	$0
Tax	$0	$0.00
Total	$270.00	$0

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