Signature Membership Plan Application

Today’s Date: ______________

Name: __________________________

Name of Parent or Guardian (if minor under the age of 18):

________________________________

D.O.B. __________________________

Soc. Sec. # ______________________

Address: ________________________

City: ___________________________

State: __________________________

Zip Code: _______________________

Telephone: ______________________

Fax: ___________________________

E-mail: _________________________

I, ___________________________, agree to enroll in the Signature Membership Plan, and be bound by all membership rules listed below and on the web site:

1.      I understand that it is my responsibility to check the web site for updates on membership rules.

2.      I understand that the use of my membership card and its benefits bind me to current rules and regulations at time of usage.

3.      I understand that membership in the Signature Health Club is not Health Insurance, an Insurance Company nor an HMO.

4.      I understand that I cannot obtain benefits for medical services at any other location unless specifically directed to do so in membership rules, or in writing by facility staff.

5.      I agree to remain current with my membership dues ($37.00 monthly) to receive member benefits, and give consent to automatic checking account and/or credit card debits for payment of my membership dues.

6.      I agree to indemnify and hold harmless, releasing from all liability, Sunshine Health Center Inc & Signature Health Services Inc. from any action, verbal or otherwise, taken by all medical providers.

7.      The initial term of membership is one (1) year. You may cancel your membership in writing after one (1) year. However, if you cancel before the end of the one-year membership period, your financial responsibility will be the Medicare cost of services you received during that period.  After one (1) year, you may cancel without penalty.

8.      Memberships will automatically renew at the end of each year under the then current provisions and payment arrangements.

9.      I will not allow anyone to use my membership card or access my membership benefits. I understand that doing so would forfeit my club membership. There is a $100.00 initial application fee.

______________________________                 __________________________

                Print Name Here                                                              Signature

This application is required at time of initial visit.