Application For The Rebounders
Questions marked by * are required.
1.
Name: *
2.
Address:
3.
City:
4.
State:
5.
Zip:
6.
Business:
7.
Email: *
8.
Phone:
9.
Status:
New Membership
Renewal
10.
Choose A Plan Below
Regular $100
Student $50
Couple $150
Student Couple $75
Family Plan $175
Student Family Plan $87.50
11.
For Family or Couple's Plan - Spouse Name
12.
Children's Name (Under 18 Only)
13.
Method Of Payment: *
Check
Credit Card
14.
Make Checks payable to: U of M Rebounders MAIL TO: REBOUNDERS * PO BOX 172054 * MEMPHIS, TN 38187-2054
15.
Card Type
Visa
Mastercard
Discover
American Express
16.
Name On Credit Card:
17.
Card #
18.
3 Digit Security Code
19.
Expiration Date
20.
Comments:
21.
How Did You Hear About Us?