Life Centered Mobility Membership Registration Form

Life Centered Mobility Membership Registration

Complete the form below to sign up for our membership service.
Name*

First NameLast Name
E-mail*
Phone Number:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date:

MonthDayYear
Which services are you interested in participating in? (Choose all the apply)

Physical or Occupational TherapyTherHab FitnessCentered Fitness Personal Training & Lifestyle Coaching
Where did you hear about us?

A Friend or colleaugeGoogleWebsiteSocial Media
Membership Rules
1. Membership is available to anyone 18 years of age or older.

2. Membership fees are paid monthly, quarterly, semi-annually or annually (cancel anytime)

3. If membership dues are more than 30 days past due, membership previleges will be revoked.

4. You will receive an invoice via email or mail to apy for membership
I have read, understood, and accepted the rules for membership.
Privacy Policy
Please read our Privacy Policy below in order to understand how your information is used and shared, and check below if you accept the policy.

https://lifecenteredmobility.com/privacy-policies-1
Privacy Policy*

I have read, understood, and accepted the PRIVACY POLICY for membership.
Please lease read our Terms & Conditions below in order to understand our policies.
Which membership option do you prefer?

Monthly $75Quarterly $225Semi Annually $450Annually $900
You will receive an invoice from LCM to pay your membership dues. You have 30 days to pay before your membership is cancelled. Your account or credit card will be charged based on the plan you choose (monthly, quarterly, semi-annually or annually). Membership can be cancelled at anytime and a prorated amount will be calculated based on the membership plan chosen. Please see our term& conditions and privacy policies on our website.
Signature*

Clear
Once you submit your application and payment, we will contact you shortly to complete your membership process.

Thank you!
Should be Empty:

Life Centered Mobility Membership Registration

Membership Rules

Privacy Policy