Gym Membership Form

Establishment of gym membership and authorization agreement to debit checking or savings account
I hereby authorize Level 11 Fitness & Development, LLC to debit or charge my checking account as indicated below. My financial institution named below will debit same to such account. I acknowledge the origination of ACH transactions to my account must comply with the provision of United States law. I acknowledge that my checking account can be charge in the amount designated, to include agreements, below until my term of commitment ends and I give a 30 day notice to end future payments. The membership cost agreed upon will remain valid for the length of the contract and indefinite thereafter unless written notice is given for cancellation or change in membership length/commitment.

Falsification, fraudulent activity, or misuse of any information provided on this sheet is punishable by law.
Financial Institution*
Routing Number*
Account Number*
Checking or Savings*
Membership Commitment*
AMERICAN HEROES DISCOUNT = Military, EMS, DR's, Nurses, Teachers
Membership Add-Ons*

Level 11 Training App $40/ monthLevel 11 Nutrition Guide $20 (one time fee)NONE
Trainer Selection
Membership Premium Services*

Personal Training (1on 1) $40 per 1 hr sessionGroup Training (2 to 6) $20 per person/per sessionCardio Kickboxing Class 4pk $40NONE
Payment Date
N/A for Paid in Full
ProRate Charge
If Applicable
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
I understand it is my responsibility to update my banking information. If my membership dues are declined, I bounce a check, or I do not have adequate funds, I agree to pay a $25 service fee.
Initials*
I understand I will be charged $10 in the event I misplace, break, or misuse my access card.
Initials*
I understand I will be charged $10 in the event I choose to cancel my membership and do not return my key card.
Initials*
This authority is to remain in full force and effect until 30 days after Level 11 Fitness & Development, LLC has received notification from me of membership termination.

I understand that this is a contract, and that termination of such contract before its commitment is fulfilled will result in a buy out of the contract.

I understand that membership add-ons and premium services that carry a monhtly charge have a 3 month commitment and continue to charge after my initial commitment is fulfilled. If I wish to cancel a add-on or premium service, I must contact a Level 11 Fitness & Development, LLC Staff member to do so.

Digital input of your name serves as the authority of your signature in agreement to the terms of this contract
Signature*

Clear
Date*

MonthDayYear
Date
Access Card Number*
Completed By Level 11 Fitness & Development, LLC Staff Member
Should be Empty:

Establishment of gym membership and authorization agreement to debit checking or savings account