Child & Family Wellness Center

Child & Family Membership Application

	Last	First	MI
Member Name:
	Street	City	Zip Code
Address:
Email :

Home Phone :		Cell Phone :
Work Phone :		Extension :
Birthdate :		Age :
Gender :	MaleFemale

Parental Information
	Mother	Father
Name
Birthdate
Employer
Work Phone
Cell Phone
Email

Club Membership Type
Individual	$100.00	per Month
Individual +1	$175.00	per Month
Family (3 or more)	$240.00	per Month
Registration Fee	$35.00	1 Time Fee

Additional Members (First Name, Last Name, Birthdate and Age)

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