Benicia Community Health & Fitness Club: * Diamond Senior

This plan requires 1 member with a maximum of 2 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

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

$50.00

$14.76

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Membership Dues	$0.00	$50.00	$0.00	0
Membership Dues	$14.76			0
Unlimited Classes	$0.00	$0.00	$0.00	0
Sub-Total	$14.76	$50.00
Tax	$0	$0
Total	$14.76	$50.00

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

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