What membership type are you interested in? *
Adult
Family
Family Health Club
Ladie's Health Club
Men's Health Club
Senior
Senior Couple
Family Information:
How many people live in your household?: *
Add all family members that live in the household
+ ADD ADDITIONAL FAMILY MEMBERS
Present Income Levels Is (Please Check Options): *
Under $8,000
$8,001 to $12,000
$12,001 to $15,000
$15,001 to $18,000
$18,001 to $20,000
$20,001 to $25,000
$25,001 to $30,000
Over $30,000
Please itemize your monthly income and expense items
INCOME
Gross Monthly Income (Before Taxes):
Spouse's Gross Monthly Income (Before Taxes):
Child Support:
Aid to Dependent Children:
Social Security Compensation:
Unemployment Compensation: *
Food Stamps:
Welfare:
Retirement Funds:
Other :
Other (Please Explain):
TOTAL MONTHLY INCOME:
EXPENSE
Rent/Mortgage :
Car/Insurance :
Fuel :
Groceries :
Utilities :
Phone :
Child Support :
Medical :
Child Care :
Alimony :
Other :
TOTAL MONTHLY EXPENSES:
A staff member will contact you for additional documentation. You will be asked to submit verification of the following items (at least 2 out of the 7 items)
Special Expenses
Three most recent payroll stubs including year to date earnings
A copy of last year’s income tax form
A copy of unemployment income
A copy of child support and/or alimony checks
Proof of mortgage or rent payments
Proof of automobile payments(s) (if applicable)
I certify that the information on this application is true and complete to the best of my knowledge. I understand the verification documents must be submitted or my application cannot be processed.
Application's Signature:
Date of Application: