78155 Athletic Club: -ONLINE GYM 1YR

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

Gender

Male Female Other

Drivers License #

Name of Guardian/Guarantor

Address of Guardian/Guarantor

Birthdate of Guardian/Guarantor

Have heart condition and told to limit exercise?

Do you feel pain in chest pain when excersing?

In past month, any chest pain when not exercising?

Lose balance from dizziness or lose consciousness?

Bone or joint issue made worse from exercise?

Take medication for heart cond./blood pressure?

Any reason why you shouldn't do physical activity?

Guardian/Guarantor Driver's License

Guardian/Guarantor Birthdate

Add-Ons for this member

PLAYROOM

$0.00 down $19.95 / month

Monthly 1st Payment

$37.83

Amount Due Today

$52.32

Service	Down Payment	Recurring	Rollover	Visits
Member 1
BASIC GYM MEMBERSHIP	$0.00	$34.95	$34.95	0
BASIC GYM MEMBERSHIP	$29.90			0
Enrollment Fee	$19.95	$0.00	$0.00	0
Sub-Total	$49.85	$34.95
Tax	$2.47	$2.88
Total	$52.32	$37.83

First Monthly 1st Payment Date: 5/15/2024

Payments will then be processed on a Monthly 1st basis there after.

Payment Info

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78155 Athletic Club: -ONLINE GYM 1YR

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

Monthly 1st Payment

Amount Due Today

First Monthly 1st Payment Date: 5/15/2024

Payment Info

Payment Info

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