Eaton Rapids Medical Center : HealthWorks

Step #1

Personal Information

General Information:

First Name:

Last Name:

Date of Birth:

Mailing Address:

City:

State:

Zip:

Phone:

Email Address:

Emergency Contact Information

Contact Name #1:

Relationship:

Phone:

Contact Name #2:

Relationship:

Phone:

Step #2

Membership Information

Membership Type

Are you a full time student (12 credits or more per term)?:

Yes

Are you 60 years old or more?:

Yes

I agree to pay for:

Single

2 Person

Family Membership

Length of Membership:

3 Month

1 Year

Family Members Information

Name:

Relationship:

Date of Birth:

Name:

Relationship:

Date of Birth:

Name:

Relationship:

Date of Birth:

Name:

Relationship:

Date of Birth:

Name:

Relationship:

Date of Birth:

Step #3

Payment Information

Choose which payment option you would prefer:

HealthWorks Location (Cash, Check, or Debit Card / Credit Card)

(PayPal Account or Debit Card / Credit Card)

Membership paid for by your company.

Step #4

That's it!

Please note that a medical clearance may be required prior to exercise participation for certain medical conditions.
Please contact (517) 663-9530 for more information.

Eaton Rapids Medical Center

HealthWorks

Step #1

General Information:

Emergency Contact Information

Step #2

Membership Type

Additional Member Information

Family Members Information

Step #3

Choose which payment option you would prefer:

Step #4

Press submit to complete the application.