Temporary Membership Extension

Name

First Last

Have your payment details changed since last debit?*

When would you like your payments processed?

Sessions will begin on September 28th please indicate when you would like your payments to begin

Preferred debit day

Debit Start Date

Card Type

Credit Card Number

Expiry Date

Enter as MM/YY

Name on card

Comments

Agreement to continue*

I wish to restart my temporary 2-1 membership

Signature*

Number

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Temporary Outdoor PT Membership