Member Request – Clayton Health & Fitness

Would you like to Add or Drop a family member?

Member Name

First

Last

Date of Birth

Email

Dependent Name

First

Last

Male or Female?

Date of Birth

Adding an additional kid?

Yes

Dropping an additional kid?

Yes

Additional Kid's Name

First

Last

Male or Female?

Date of Birth

Adding a 2nd additional kid?

Yes

Dropping a 2nd additional kid?

Yes

Additional 2nd Kid's Name

First

Last

Male or Female?

Date of Birth

Adding a 3rd additional kid?

Yes

Dropping a 3rd additional kid?

Yes

Additional 3rd Kid's Name

First

Last

Male or Female?

Date of Birth

Adding a 4th additional kid?

Yes

Dropping a 4th additional kid?

Yes

Additional 4th Kid's Name

First

Last

Male or Female?

Date of Birth

Barcode Number

(If you are completing this form away from the center please stop by the service desk for your child's new barcode on your next visit)

By checking the box you are confirming that you read the disclaimer above this form and authorize Clayton Health and Fitness to charge your billing on file.

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Personal Information

Personal Information

(If you are completing this form away from the center please stop by the service desk for your child's new barcode on your next visit)

New Information

Membership Request

Personal Information

Personal Information

(If you are completing this form away from the center please stop by the service desk for your child's new barcode on your next visit)

New Information

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