Enrollment Form: Kewanee warehouse

Member Details

First Name*

Last Name*

Gender*

Phone Number*

Email*

Date of Birth*

Insurance Provider*

Insurance Provider ID*

Address

Street Address*

City*

ZIP Code*

State*

Country*

Emergency Contact

First Name*

Last Name

Phone Number*

Billing Address

Same as home address

Street Address*

City*

ZIP Code*

State*

Country*

Select Membership

Memberships Sorted Alphabetically

[TRIAL] Single Lift Pass

1 day

1 days / payment

$7 one-time

[TRIAL] Week Pass

1 week

1 days / week

$20 one-time

Monthly

ongoing

Unlimited

$40 / month +$20.00 one-time signup fee

Yearly Gym Membership

1 year

Unlimited

$400 one-time +$20.00 one-time signup fee

DESCRIPTION: Non refundable

Account Password

Password

too short

Confirm Password

Credit Card

All transactions are secure and encrypted

Card Number

Expiry Month

Expiry Year

CVV / CVC

Zip Code