Enrollment Form: Buff Daisy Fitness

Member Details

First Name*

Last Name*

Gender

Phone Number*

Email*

Date of Birth

Insurance Provider*

Insurance Provider ID*

Address

Street Address*

City*

ZIP Code*

State*

Country*

Emergency Contact

First Name

Last Name

Phone Number

Billing Address

Same as home address

Street Address*

City*

ZIP Code*

State*

Country*

Select Membership

Memberships Sorted Alphabetically

Beachbody Bootcamp - first time joining

ongoing

Unlimited

$40.00 / Week

Beachbody Bootcamp - returning member

ongoing

Unlimited

$30.00 / Week

Day Pass - class pass

1 day

1 session / payment

$15.00 One-time

Day Pass - guest pass

1 day

1 day / payment

$15.00 One-time

Day Pass - member w/ guest

1 day

1 day / payment

$10.00 One-time

Monthly - 20-60 years old

ongoing

Unlimited

$35.00 / Month

Monthly - over 60 years old

ongoing

Unlimited

$30.00 / Month

Monthly - under 20 years old

ongoing

Unlimited

$30.00 / Month

One Month Pass

1 month

Unlimited

$40.00 One-time

One Week Pass

1 week

Unlimited

$20.00 One-time

Personal Training - 1 hour 1x week

ongoing

1 session / week

$200.00 / Month

Personal Training - 1 hour 2x week

ongoing

2 sessions / week

$360.00 / Month

Personal Training - 1 hour 3x week

ongoing

3 sessions / week

$480.00 / Month

Membership Settings

Payment Method

Account Password

Password

too short

Confirm Password

Credit Card

All transactions are secure and encrypted

Card Number

Expiry Month

Expiry Year

CVV / CVC

Zip Code