Your Fitness. Your Way
Couples/Single Parent
Plan Applicant Information
Main - Couple
COUPLE/SINGLE PARENT PLAN APPLICANT INFORMATION
First Name
*
Last Name
*
Phone
*
Email
*
Date Of Birth
*
Gender
*
Male
Female
Non-Binary
Other
Marital Status
Married
Unmarried
Prefer not to answer
Mailing Address
*
Mailing Address
Street Address
Street Address
Mailing Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Emergency Contact Name
*
Emergency Contact #
*
Monthly Dues
Monthly Surcharge if applicable: Additional children 0-20 years of age are $10 per month, additional children 21 and up are $15 per month, and additional children 21 and up added to platinum membership are $30 per month.
Consultation Fee
Location
Offer
*
I would like to signup for 2 FREE months of Membership Plus
No
Yes
I Agree To Terms
*
I understand that my free membership plus will last 2 months. If I would like to cancel my free membership plus, I must contact membership accounting prior to the 23rd on the last free month. If membership plus is not cancelled I will be charged $42 starting on the date below. This membership plus upgrade will be billed ongoing until membership accounting is contacted.
Membership Plus Expiration Date
Add Additional Membership Plus User
I would like to signup another user for 2 FREE months of Membership Plus
I Agree To Terms
*
Additional membership plus user will have the same trial period as primary member. Second user will be charged an additional $20 starting on date listed above until membership plus trial is cancelled. This is in addition to the $42 fee for primary.
CO-APPLICANT INFORMATION
Relationship to Applicant
Co-Applicant First Name
Co-Applicant Last Name
Co-Applicant Email
Co-Applicant Phone
Co-Applicant Date Of Birth
Co-Applicant Gender
Male
Female
Non-Binary
Other
Do You Have Dependents?
Yes
No
FIRST DEPENDENT ON MEMBERSHIP
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Dependent First Name
Dependent Last Name
Date Of Birth
*
Gender
Male
Female
Non-Binary
Other
Relationship to Applicant
Add A Second Dependent?
Yes
SECOND DEPENDENT ON MEMBERSHIP
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Dependent First Name
Dependent Last Name
Date Of Birth
*
Gender
Male
Female
Non-Binary
Other
Relationship to Applicant
Add Third Dependent?
Yes
THIRD DEPENDENT ON MEMBERSHIP
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Dependent First Name
Dependent Last Name
Date Of Birth
*
Gender
Male
Female
Non-Binary
Other
Relationship to Applicant
Add A Fourth Dependent?
Yes
FOURTH DEPENDENT ON MEMBERSHIP
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Dependent First Name
Dependent Last Name
Date Of Birth
*
Gender
Male
Female
Non-Binary
Other
Relationship to Applicant
Add A Fifth Dependent?
Yes
FIFTH DEPENDENT ON MEMBERSHIP
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Dependent First Name
Dependent Last Name
Date Of Birth
*
Gender
Male
Female
Non-Binary
Other
Relationship to Applicant
Add A Sixth Dependent?
Yes
SIXTH DEPENDENT ON MEMBERSHIP
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Dependent First Name
Dependent Last Name
Date Of Birth
*
Gender
Male
Female
Non-Binary
Other
Relationship to Applicant
Add A Seventh Dependent?
Yes
SEVENTH DEPENDENT ON MEMBERSHIP
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Dependent First Name
Dependent Last Name
Date Of Birth
*
Gender
Male
Female
Non-Binary
Other
Relationship to Applicant
Add A Eighth Dependent?
Yes
EIGHTH DEPENDENT ON MEMBERSHIP
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Add A Sixth Dependent?
Yes
Dependent First Name
Dependent Last Name
Date Of Birth
*
Gender
Male
Female
Non-Binary
Other
Relationship to Applicant
Add A Ninth Dependent?
Yes
NINTH DEPENDENT ON MEMBERSHIP
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Dependent First Name
Dependent Last Name
Date Of Birth
*
Gender
Male
Female
Non-Binary
Other
Relationship to Applicant
Add A Tenth Dependent?
Yes
TENTH DEPENDENT ON MEMBERSHIP
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Dependent First Name
Dependent Last Name
Date Of Birth
*
Gender
Male
Female
Non-Binary
Other
Relationship to Applicant
Referred By
ADDITIONAL APPLICANT INFORMATION
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Employer Name
Work Phone
Employer Address
Employer Address
Employer Address
Employer Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
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