Office use:
Staff member: _______________ Membership expiration date: _____/_____/______
Amount paid: ________________ Scan Code: _____________
South Plains College Physical Education Complex
Enrollment Form
Date of Application _____/_____/_____ Length of membership: 1 month 3 month
(Circle) 6 month 9 month 1 year
Membership Type: SPC Employee SPC Family Community Corporate
(Circle one) LISD Wellness Covenant Gold Card Seniors 65+
Last Name: ___________________________First Name: __________________
Mailing address: ___________________________City/Zip: _________________
Phone: __________________________Alternate:_________________________
Emergency Contact: __________________________Phone:___________________
Sex: M F D.O.B. ____/____/____ Photo ID required
Children under 16 are not eligible for membership. Anyone falsely representing his/her age will forfeit membership with no refund.
Parent/ Guardian signature if under 18: _________________________________
No one, with any of the following conditions, should exercise without first obtaining their physician’s consent:
Ø Heart Trouble
Ø Chest pain or tightness
Ø Faint or have dizzy spells
Ø High Blood pressure
Ø Orthopedic problems
Ø Diabetes
Ø Seizures
Ø Other conditions that might prevent you from safe exercising.