Contract Agreement Membership Application Agreement Member InformationMember Name(Required) First Last Member Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Email(Required) Address InformationMailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency InformationEmergency Contact Name(Required)Emergency Contact Phone(Required)Legal/SignatureDo you consent to receive information from Francesville Fitness via email?(Required) Yes No Is Member 18 years of age or older?(Required) Yes, Member is 18 or older No, Member is under 18 (parent/guardian must sign) If under 18, a parent or guardian must sign on behalf of the member.Member Signature(Required)Sign in the box. If signing on behalf of a minor, this is the parent or guardian signature.Parent or Guardian InformationRequired if Member is under 18.Parent or Guardian Printed Name(Required)Relationship to Minor(Required)Do you consent to the Photo and Video Release?(Required) Yes No Allows Francesville Fitness to use photos/videos of the member for marketing purposes.Parent or Guardian Signature(Required)Sign in the box below using your mouse or finger.
