Enrollment Form: Pioneer 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*

Country*

State*

Emergency Contact

First Name

Last Name

Phone Number

Billing Address

Same as home address

Street Address*

City*

ZIP Code*

Country*

State*

Select Membership

Memberships Sorted Alphabetically

18 AND UNDER STUDENT

1 year

Unlimited

$20.00 / Month +$10.00 One-time fees

DESCRIPTION: FOR KIDS ATTENDING SCHOOL IN PERSHING COUNTY 18 AND UNDER

Daily (Drop-In)

1 day

1 day / payment

$10.00 / Session

DESCRIPTION: this membership will expire 24 hours after purchase!!!

GUARDIAN PLAN

Group Plan

10 years

1 day / payment

$0.00 / Year

Single Adult

1 year

Unlimited

$40.00 / Month +$15.00 One-time fees

DESCRIPTION: This is a one year membership 30 day notice of cancellation… a fee of 30 dollars to cancel before one year is up without 30 day notice…

Yearly

365 days

Unlimited

$365.00 One-time +$15.00 One-time fees

DESCRIPTION: This membership is for one year total access paid one time equaling 1 dollar a day for 365 days total…

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