Powell Wellness Center: GOLD 1 Year Membership

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

$25.00 down $25.00 / month

Oxygen Room

$18.00 down $18.00 / month

Monthly Payment

$130.00

Amount Due Today

$162.00

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Enrollment Fee	$32.00	$0.00	$0.00	0
Free Class Access	$0.00	$0.00	$0.00	0
Towel Service	$0.00	$0.00	$0.00	0
Tanning Membership	$0.00	$0.00	$0.00	0
Membership Dues	$130.00	$130.00	$130.00	0
Sub-Total	$162.00	$130.00
Tax	$0	$0
Total	$162.00	$130.00

First Monthly Payment Date: 11/22/2024

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

Other Fee Information

Annual Assessment (Per member) of $29.00 will be billed on a Annual basis starting 12/15/2024

Payment Info

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Powell Wellness Center: GOLD 1 Year Membership

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

Monthly Payment

Amount Due Today

First Monthly Payment Date: 11/22/2024

Other Fee Information

Payment Info

Payment Info

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