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Membership Inquiry Form
 
First name: 
Last name: 
Address: 
City: 
State: 
Zip Code: 
Phone:  ( )
Email: 
 
Are you interested in receiving a free workout? Yes No
Please select your preferred club:
How did you hear about Mercy HealthPlex?
Are you interested in a corporate membership? Yes No
Please enter the company name:
Are you interested in receiving our monthly electronic newsletter? Yes No
 
Please indicate which programs and services you are interested in (Check all that apply):
Exercise Classes Yoga/Pilate
Weights and Cardio Equipment Personal Training
Aquatics Physical Therapy
Weight Management Massage Therapy
KidsFit Programs    
 
 




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