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Fitness First Healthcare,
LLC
Individual and Family Membership Application (Membership is NOT required for insurance products.) Applicant Information: Member ID #________ Primary Member’s Name: _____________________________________________________________ (Must match the name on the photo identification being submitted.) Type of Membership: _____Individual _____Family
Program(s): _____Fitness First Healthcare (FFH) Membership only (includes our Personal Trainer Locator Service and is required in order to obtain the pricing noted for all of our other Programs) _____Family Protection Plan (FPP) _____Medical, Dental, Hearing, Vision, etc. Discount Program (FFH-DP)
Annual Fees: FFH Individual = $30 / FFH Family = $75 / FPP (Individual and Family) = $120 Monthly Fees: FFH-DP (Individual and Family) = $29.95
Please call us for the application for the Limited Benefit Hospital Indemnity Insurance Policy program as additional information is required. FFH Membership is also required in order to obtain the discounted pricing negotiated for this Program.
Addresses: Mailing: _____________________________ Physical: _______________________________ _____________________________ _______________________________ _____________________________ _______________________________ E-Mail Address: ________________________________________________________________ Sex: ___M ___F Date of Birth ___/___/______ Marital Status ____ (mm/dd/yyyy) (Single, Married, Divorced)
Home Phone: __________________________ Work Phone: ____________________________ Fax Number: ___________________________ Cell Phone: _____________________________ Type of photo Identification being submitted: D/L _____ School ID _____ Other State ID _____
Dependent Information: Programs include spouse, unmarried children & stepchildren age 25 and under. Eligibility may also extend to certain other relatives living with primary member including any IRS dependents, unmarried individuals age 21 & under, and any elderly person age 60 years & over. Additional documentation may be required for verification purposes. All non-qualified dependents will automatically be removed by Fitness First Healthcare.
_________________________________ ___/___/____ ___ _________________ Dependent’s Name: Date of Birth Sex Relationship _________________________________ ___/___/____ ___ _________________ Dependent’s Name: Date of Birth Sex Relationship _________________________________ ___/___/____ ___ _________________ Dependent’s Name: Date of Birth Sex Relationship (Please use a separate sheet of paper for additional Dependent information.) Payment Method: Initial Annual Membership Fees (as
noted above) must be submitted with this form using Check, Money Order,
Certified Funds or Credit Card. All subsequent Annual
Membership Fees and all Monthly Fees will be automatically paid using one of the methods listed below. Please provide the information for one
selection only. Bank Draft: ____ Checking (include a separate voided check) ____Savings (include a voided deposit slip) ______________________________________________________________________________ Bank Name and Branch Location ____________________________________ ____________________________________ Name on the Account Account Holder’s Signature ______________ __________________ ____________________________________ Initial Check # Bank Routing Number Account Number Credit Card ___Visa ___Master Card ___American Express (The Mailing Address noted above must match the Mailing Address on record with the credit card company for the credit card you are using.) ____________________________________ ____________________________________ Name on the Credit Card Credit Card Number ________________ __________________ ____________________________________ Expiration Date Today’s Date Card Holder’s Signature An Invoice for the applicable Annual Membership Fees will be mailed approximately 45 days prior to your annual renewal date. Any updates to the credit card information on file will need to be made prior to your renewal date. A 30-DAY WRITTEN NOTICE IS REQUIRED TO CANCEL ANY MEMBERSHIP IN ITS ENTIRETY. Fees not authorized on any of the renewal dates will suspend your membership and incur an additional $5 late fee plus an additional $5 per month administration fee for each month the membership fee is late upon reactivation of the applicable membership. MEMBERSHIP WILL BE CANCELLED IN ITS ENTIRETY AFTER 60 DAYS OF NON-PAYMENT. _______________________________________ __________________________ Applicant’s Signature Today’s Date
All New Members Must Read, Initial and
Sign each item below:
___ I understand that Fitness First Healthcare is providing a locator service ONLY and is not in any way affiliated with any of the service providers listed on its website. ___I understand that Fitness First Healthcare will make every effort to ensure the information provided on its website is true and accurate at the time of its initial posting. I further understand that it is MY responsibility to confirm the information listed with the service provider is still accurate and valid for my wants and needs. ___I will contact Fitness First Healthcare in the event any information listed on the Fitness First Healthcare website is determined to be out of date or in some other way inaccurate. ___I understand that the information provided on the Fitness First Healthcare provider pages are proprietary and password protected. The use of this information is strictly for Fitness First Healthcare Personal Trainer Locator Service Members. Any unauthorized use or dissemination of this information will be grounds for termination of my membership and a forfeit of any and all membership fees paid. Any unauthorized use or dissemination of this information causing damage in any way to Fitness First Healthcare, LLC, and or any of its owners, agents, employees, representatives, associates or service providers will be grounds for legal remedies and cost recoveries for any legal pursuits. ___I understand that a unique log-in and password will be given to me after my Personal Trainer Locator Service Membership Application has been approved. Each member of a Family Membership will have their own unique log-in information, as well. This information is to be used by the specific family member only and the entire membership is subject to cancellation if any one family member violates the provision listed above. ___I understand that Fitness First Healthcare does not dictate what discounts are to be given by the individual service providers, therefore, Fitness First Healthcare cannot guarantee that any specific savings will be given or realized. ___I understand that Fitness First Healthcare, its owners, agents, employees and representatives are not responsible for the outcome of any services received by any service provider associated with Fitness First Healthcare, either directly or indirectly and I agree to hold Fitness First Healthcare, et al, harmless for any negative outcome of any services received by any of the service providers in any of our Programs. ___I understand that Fitness First Healthcare must receive a written request to cancel my membership at least 30 days prior to my next annual membership fee renewal date. Failure to do so will result in the annual membership fee being charged against the appropriate account noted above and that no refund will be given once the membership fee has been received. ___I understand that E-mail and faxed requests to cancel my membership ARE NOT acceptable methods to cancel the membership and any subsequent renewal fee collections. By signing below, I understand and agree to abide by Fitness First Healthcare’s Member Terms & Conditions and by the policies and provisions listed above as indicated by my initials of acceptance. _______________________________________ __________________________ Applicant’s Signature Today’s Date Fitness First Healthcare, LLC Fax: (719) 748-8275 65 Bear Trail /
www.fitnessfirsthealthcare.com |