Powell Wellness Center: All Access 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

Add-Ons for this member

Locker

$0.00 down $8.00 / month

Monthly Payment

$56.00

$132.36

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Enrollment Fee	$125.00	$0.00	$0.00	0
Complementary Guest Passes	$0.00	$0.00	$0.00	5
Membership Dues	$0.00	$56.00	$0.00	0
Prorated Dues	$7.36			0
60 Minute Annual Assessment	$0.00	$0.00	$0.00	1
Equipment Orientation	$0.00	$0.00	$0.00	1
Sub-Total	$132.36	$56.00
Tax	$0.00	$0.00
Total	$132.36	$56.00

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

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