Membership Registration Form

Name*

First NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Phone Number:*

Area CodePhone Number

Please give a brief description of anything that may hinder* your participation in our classes (i.e. surgeries, injuries, etc.):

*Most exercises can be modified to compensate for limitations

Please give a brief description of your physical fitness experience and current level:

Membership Options

One Time Registration Fee$10.00

If you are starting after the first week and you want a monthly membership, please pay ONLY the registration fee. Your prorated membership will be calculated at your first class.

Flex Punchcard$120.00

10 classes + the 11th FREE. No commitment to a set schedule. Great for those who need flexibility!

Monthly Membership (2x/wk)$64.00

2 classes per week. Please select this option if you are starting at the beginning of the month. Only pay the registration fee if you are starting after the first week. Your prorated membership will be calculated at your first class.

Monthly Membership (3x/wk)$84.00

3 classes per week. Please select this option if you are starting at the beginning of the month. Only pay the registration fee if you are starting after the first week. Your prorated membership will be calculated at your first class.

Total $0.00

By clicking the "Pay Now" button you are submiting your online application and will be re-directed to Paypal to submit your payment. Once we recieve your payment, we will contact you about your Membership.

Thank you!

Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info

WELCOME TO MOSES LAKE PILATES