Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone 1 *

(###)

###

####

Emergency Phone *

(###)

###

####

Agreement to Follow Direction *

I agree to observe and obey all posted rules and warnings, and further agree to follow any oral instructions given by Warren Health & Fitness employees or representatives.

Fees *

I agree to pay membership fees to Warren Health & Fitness.

Electronic Signature Consent *

By checking here you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy.