Name *

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Last Name

Date

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DD

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Address

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Address 2

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Physician's #

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Emergency Contact #

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I have enrolled in a program of strenuous physical activity including but not limited to weight training and use of various aerobic conditioning activities. I hereby affirm that I am in good physical condition and do not suffer from any condition or disability that would create risk of injury to me or prevent or limit my participation in this exercise program. *

Checking this box serves as your electronic signature

I hereby authorize CrossFit Helena to automatically process my monthly membership dues by way of debit entry to the specified bank account below, until notification to the contrary is given. I understand that the automatic debit will be processed on the due date of my choosing for the full amount due at the time of processing. I also understand that I will receive a 5% discount on membership dues by enrolling in autopay. *

Checking this box serves as your electronic signature

I do not wish to enroll using autopay

Name On Account

First Name

Last Name

Billing Address

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City

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NOTE: You may choose to bring in a voided check, select the type of account, select a due date, and sign. Thank you for signing up with our box! If you would like to receive monthly receipts, please let us know.

I would like to receive monthly receipts by e-mail

I don't need monthly receipts