Powell Wellness Center: All Access 62+ Individual

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?

Emergency Contact

Name

Phone

Birth Date

Source

Add-Ons for this member

Locker

$0.00 down $10.00 / month

Monthly Payment

$50.00

Amount Due Today

$101.64

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Enrollment Fee	$100.00	$0.00	$0.00	0
Membership Dues	$0.00	$50.00	$0.00	0
Prorated Dues	$1.64			0
60 Minute Annual Assessment	$0.00	$0.00	$0.00	1
Equipment Orientation	$0.00	$0.00	$0.00	1
Complementary Guest Passes	$0.00	$0.00	$0.00	5
Sub-Total	$101.64	$50.00
Tax	$0	$0
Total	$101.64	$50.00

First Monthly Payment Date: 7/1/2025

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

Other Fee Information

No ACH Discount (Total) of $3.00 will be billed on a Monthly basis starting 6/29/2025

Payment Info

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Powell Wellness Center: All Access 62+ Individual

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

Monthly Payment

Amount Due Today

First Monthly Payment Date: 7/1/2025

Other Fee Information

Payment Info

Payment Info

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