Green & Grind Member Application
Thank you for your interest in becoming a Green & Grind member! Please note that payment is NOT collected at the time of form submission, as each application will be reviewed before membership approval. If you have any other questions regarding memberships, lessons, payment options, or any of our services, please feel free to contact us at thegreenandgrind@gmail.com.
Membership Type
*
Practice Lite
Unlimited Individual
Couple Membership
Family Membership
Personal Information
Primary Applicant’s Name
*
First Name
Last Name
Residential Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Address (if different from residential address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant’s Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Applicant’s Email Address
*
example@example.com
Applicant’s Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Green & Grind Reference
I am personally known by the following member at Green & Grind who will serve as a reference. I authorize this individual to disclose information to Green & Grind.
First Name
Last Name
Family/Couple’s Personal Information
Spouse/Partner’s Name
*
First Name
Last Name
Spouse/Partner’s Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse/Partner’s Email
example@example.com
Spouse/Partner’s Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name and Date of Birth for dependents under 18 yo
*
Submit
Should be Empty: