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Full Name:

Home Address Line1:

Street address, P.O. box, company name, c/o

Home Address Line2:

Apartment, suite, unit, building, floor, etc.

City:

State:

Zip / Postal Code:

Preferred Method of Communication: Phone Email

Home Tel Number:

Business Tel Number:

Mobile Tel Number:

Email Address:

Full Name of Spouse:

Home Address Line1:

Street address, P.O. box, company name, c/o

Home Address Line2:

Apartment, suite, unit, building, floor, etc.

City:

State:

Zip / Postal Code:

Home Tel Number:

Business Tel Number:

Mobile Tel Number:

Email Address:

Full Name of Child:

Date of Birth: / /

Full Name of Child:

Date of Birth: / /

Full Name of Child:

Date of Birth: / /

Full Name of Child:

Date of Birth: / /

Full Name of Caregiver:

Home Address Line1:

Street address, P.O. box, company name, c/o

Home Address Line2:

Apartment, suite, unit, building, floor, etc.

City:

State

Zip / Postal Code:

Home Tel Number:

Mobile Tel Number:

Areas of Interest:

(check all that apply)

	Children's Classes		Wellness Classes		Spa
	Adult Fitness		Retail & Trunk Shows		Special Events

Approval of Membership

This application will be subject to approval by citibabes, in its sole and absolute discretion, without regard to race, color, religion, sex, sexual orientation, the applicant will be required to sign a membership event an applicant is not accepted, the applicant's (15) business days of receipt of such notice.

The applicant shall promptly notify citibabes in writing of any changes in address, phone number, billing information, and/or caregiver information.

Referred By:

Today's Date: / /

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This application for membership shall not be binding upon citibabes until approved.