Use this form to apply for membership in the Womens Wellness Center
First Name: (required)
Middle Initial:
Last Name: (required)
Street Address: (required)
City: (required)
State: (required)
Zip Code: (required)
Home Phone: (required)
Cell Phone:
Work Phone:
Employer:
Your Email: (required)
Date of Birth: (required. format MM/DD/YYYY)
Emergency Contact Name: (required)
Emergency Contact Phone: (required)
Please select your Membership Package (required)
Monthly  $59.95 (+tax)
Please select your Payment Method (required)
Checking or Savings Account
Monthly Automatic Withdrawl from my checking account
Annual Automatic Withdrawl from my checking account
Bank Name (required)
Bank Routing Number (required) help with routing number
Bank Account Number (required) help with account number

Credit Card
Monthly Automatic Charge to my credit card
Annual Automatic Charge to my credit card
Card Type (required)
Card Number (required)
Card Expiration  /  (required mm/yyyy)
CVV (required) Help finding Card Verification Value help finding CVV
Yes! I want to help support programs for women and girls. Please add the amount below to my monthly withdraw as a tax deductible donation for the Scholarship Fund.
additional donation amount:
How did you hear about us?
(required)
TERMS AND CONDITIONS
I understand that I cannot transfer this membership to any other person.

I verify no promise to guarantee other than those written on this agreement was made to me by this facility or its employees.

I agree to cooperatively use this facility and understand that my membership can be cancelled if my behavior is inappropriate and/or disruptive.

I understand membership fees are owed whether I have used the facility or not, within the time stated. This facility has the right to cancel membership based on unpaid fees.

Cancellation Policy:
Membership can be cancelled in writing at anytime. Membership will conclude the 1st day of the month following notice of cancellation.

Release of Liability:
In consideration of acceptance for access to Women's Wellness Center, and intending to be legally bound, I do hereby for myself, my heirs, administrator, representatives, and assignees, waive and forever release Women's Wellness Center, its directors, employees, trainers, and owners from any claims for damages or personal injury arising from use of Women's Wellness Center facilities or equipment. I accept full responsibility for any personal property and effects, including but not limited to, responsibility for damage to or loss of clothing, equipment, eyeglasses, etc. Further, in the event of any injury, I do hereby give my permission and consent to authorize such first aid and/or medical and/or hospital care or treatments as deemed appropriate.

I understand and am aware that strength, flexibility, and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury and even death, and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death.

I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I do hereby acknowledge that I have been informed of the need for a physician's approval for my participation in an exercise/fitness activity, or in the use of exercise equipment. I also acknowledge that it has been recommended that I have a yearly physical examination and have been given permission by my physician to participate, or that I have decided to participate in this activity and use of equipment without the approval of my physician, and do hereby assume all responsibility for my participation, activities, and utilization of equipment in my activities.

SUBMITTING THIS FORM CERTIFIES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO THE TERMS

The Women's Wellness Center respects your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes and requires us to do so.
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