SHV

Athletic Republic(Mercury Enterprises,LLC)

Agreement for Membership Contract

(School/Organization)

(Email Address)

Athlete Information (Please Print)

RegisteredAthlete: Name-Last First DOB Home Phone #

Address City State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY ZipCode

Emergency Contact  Relationship  Phone #

Programs and Fees

Gold Membership

o   12-Month    $189.00/month 6-Month    $239.00/month

Silver Membership

o    12-Month    $99.00/month 6-Month    $139.00/month

Youth Membership

o   12-Month    $79.00/month 6-Month    $109.00/month

Endurance Membership- Computrainer

o   12-month    $100.00/month Special:    $80.00/month

Assessment Fee$49.00/assessment

1-on-1 Training Session$50.00/session

Cancellation/No-Show Fee$10.00/occurrence

Membership Contract

The Athletic Republic (Mercury Enterprises, LLC) GOLD/SILVER/YOUTH Membership is a (minimum) ______ month contract with Athletic Republic (Mercury Enterprises, LLC) paid through automatic and re-occurring monthly installments of $__________, based on the programs and fees outlined above. After the minimum commitment has been made the membership contract will be automatically renewed each month on behalf of the member until the member submits the 'Membership Discontinue Form'(available at both Athletic Republic facilities MLU/ SHV). __________(Initial)The Membership Discontinue Form must be received at 'Home Facility' 14 days prior to monthly renewal date to cancel this membership contract.  The monthly membership fee will be debited from the account listed on today’s date and on this date each month (or the 25th of each month, whichever is earlier).  The account you have listed shall be debited each month thereafter this automatically renewing the membership each month (unless cancelled).

Acknowledgement of Purchaser

I (We), the below named Purchaser(s), hereby represent and state the following:

I have read and understand the terms defined above and of the GOLD/SILVER/YOUTH Membership benefits and agree to the terms listed thereof.

I understand that my credit card /checking account will be debited each month beginning today and for the next ______ consecutive months as payment for the membership and that the membership fee charged can be increased January 1st of each year, at a rate no more than 5.0% per year.

I understand that changes and additions to the membership benefits may occur from time to time and that any such changes and additions will not affect the terms of this agreement and therefore agree to the same unless it can be shown that the value of the membership has been lessened by any such modifications.

I understand that although the meaning and purpose of the GOLD/SILVER/YOUTH Membership is long-term service, Athletic Republic (Mercury Enterprises, LLC)reserves the right to refuse the renewal of any membership any time after twelve months if the 'user' did not train at least 40 sessions during any twelve month period.

I understand that I will be charged $10.00 per occurrence for each time the 'Registered Athlete' does not attend a scheduled session or fails to give at least 24 hours notice when canceling a scheduled appointment.

I understand that the GOLD/SILVER/YOUTH Membership is non-refundable and non-transferable.

I understand that I may cancel this membership within 30 days of purchase by submitting the Membership Discontinue Form to 'Home Facility', with a cancellation penalty of $200.00.

I understand that I am responsible for the acceptance of the monthly debit to my credit card / checking account. If the credit card / Checking Account ACH is denied for any reason, email notice will follow within 5 business days. At which time, the purchaser will be given 5 additional business days to resolve the issue. If payment is unable to be made within 10 business days of the monthly renewal date, a $100 payment penalty will be assessed every 10 business days until payment is made. If payment is unable to be made, the membership will be cancelled and a cancellation penalty of $500 (or the remaining balance of the minimum commitment, whichever is less) will be assessed.

I understand that I may put my membership 'on-hold' for up to 1 Month per year, during which time I must provide proof that I will be out-of-town. In doing so, I understand that the Membership will be extended another month.

I understand that in the unfortunate case where the 'Registered Athlete' is injured and cannot participate in any athletic activities, the Membership can be put 'on-hold'. This requires a note from the treating Doctor.

I understand that I may discontinue my GOLD/SILVER/YOUTH Membership after ______ months by submitting the Membership Discontinue Form to 'Home Facility'.

Payment Calculator

Monthly Membership Fee:$    Payment Notes:

Cord Training Package:$

Assessment Fee:$

Additional Services:$

Initial Debit to CC /Checking:$ Date:

Recurring Monthly Debit to CC / Checking: $  on the of every month for months.

Payment Information (Checking Account Credit Card) Choose one If Checking Account has ACH Form been Completed? Yes / No

Name on Credit Card: Type of Card: Visa MasterCard Discover

Card Number:　　　　　　　　Expiration:　 1 2 3 4 5 6 7 8 9 10 11 12 / 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

V-Code:　　　ZipCode:　　Cardholder’s Signature:

I have read this contract in its entirety, and I agree to all the terms herein.　I have read and understand all of the aspects of this membership contract.　I agree to pay in-full the entire amount of the monthly membership and agree that no modifications or refunds of this monthly membership contract can be made once I have entered into this contract.

Athlete Name Parent/Guardian (if necessary) Date

August 2009