Welcome To Integrated Health Centre - Online Member Sign Up

Selected Home Club: 24 hrs. [Club Details]


NO COMMITMENT $30/MTH - $24 DOWN PAYMENT W FOB
$24 Enrolment Fee

Membership Includes:
24 Hour Access
Free Wifi


Additional Information:
$39 annual fee billed April 1
**NEW MEMBERS please come in during staffed hours to purchase your Fob for $5 plus tax**



MEMBERSHIP BREAKDOWN
Initial Payment
Card Fee
$5.00
Enrollment Fee
$24.00
Monthly Due
$30.00
Taxes
$7.67
Amount due now:
$66.67

Payments Starting on 15-Jan-20
Monthly Due
$30.00
Taxes
$3.90
Total:
$33.90
MEMBER INFORMATION
 
Please complete all of the following fields. You only need to enter 1 telephone contact; when entering a telephone number please enter all 10 digits without any spaces; when entering the postal code please enter all 6 characters without any spaces.
 
First Name   Last Name   Gender   Date of Birth
    Male Female  
 
Street Address   Province/State   City   Postal/ZIP   Email (Username)
       
 
Home Tel.   Mobile   Emergency Contact   Emergency Tel.   Referral Source
       
 

INITIAL PAYMENT INFORMATION
 
Card Type   Card Number  
   
 
Expiry Date   Cardholder Name   CSV [?]
   
 
Use address above for billing information
 
Street Address   Province/State
 
 
City   Postal/ZIP
 
 
MONTHLY PAYMENTS INFORMATION
 
Use same information as initial payment
 
Card Type   Card Number  
   
 
Expiry Date   Cardholder Name   CSV [?]
   
 
Use address above for billing information
 
Street Address   Province/State
 
 
City   Postal/ZIP
 
 

OTHER MEMBERSHIP TERMS
 
Before finalizing your purchase, please carefully read the following terms and conditions.
 
 
Electronic Signature

I understand that my electronic signature below constitutes a legal signature confirming acceptance of the membership agreement.


Please sign below