Membership Application

MEMBER INFORMATION

Last Name *

First Name *

Middle Name

Gender *

Date of Birth *

Select Date

CONTACT INFORMATION

E-mail *

May we contact you with Wellness Center updates? *

Yes
No

Mailing Address *

City *

State *

Zip Code *

Home Phone *

Cell Phone

Emergency Contact Name *

Emergency Contact Phone *

MEMBERSHIP INFORMATION

Membership Type *

Staff      - No Charge
Faculty   - No Charge
Student - No Charge
Alumni   - $150 annually

Number of times per week you workout *

Time of day you workout *

Activity of interest *

Latin impactZumba
StepSpinning
JoggingKickboxing
PilatesYoga
VolleyballBasketball
Free WeightsCardio Machines
Core ConditioningOther

INSURANCE INFORMATION

Insured Name *

Group Number *

Identification Number *

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