Health Coaching Centers Membership & Application

Integrity Health Coaching Centers Application & Membership Agreement

Get Your Fit Together!
Client Name*

First NameLast Name
Client E-mail*
Client Phone*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth

MonthDayYear
How did you hear about us?*
If you chose family or friend please list name
Emergency Contact*
Energency Contact Phone Number

Area CodePhone Number

Membership Options

BodyBurn - Small group training available Tue, Thur, Sat. See website for details.$29.00

Monthly Payment

EZCOACH Full Service Membership - Includes: New Program Provided Every 8 Weeks, Program Instruction, Meal Planning, Shopping List, Exercise Prescription, Access to Health Coaches,Club Access 24/7$79.00

Monthly Payment

BodyBurn PIF 1 year$348.00

EZCOACH Full Service Membership Paid in Full 6 Months - Save $24!! $549.00

EZCOACH Full Service membership Paid in Full 1 year - Save $99!! $948.00

Total $0.00

Payment Method
Credit	Express
Credit	What is PayPal?

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

I, the applicant for this membership form warrant the truthfulness of the information provided in this application.
I understand that checking the box below constitutes a legal signature confirming that I acknowledge and agree to the terms & conditions.
A Coach will contact you on what your next steps will be. We always strive to respond well within a 24 hour period but, please kindly allow up to 48 hours to receive a response to your email. Thank you.
Preferred Method of Contact?
Best time to reach you by phone?

:HourMinutesAM/PM Option
Should be Empty:

Integrity Health Coaching Centers Application & Membership Agreement