Your info:

FIRST NAME

LAST NAME

Your email:

Phone number:

(###)

###

####

Terms of billing:

On the 3rd of each month, I will be billed for my membership dues. I will give at least 7 days notice before the end of the month if I decide to end or modify my membership. My monthly membership amount is:

OR sliding scale amount as agreed upon with Room:

Customer bank account information:

Routing number:

Account Number:

Account type:

By typing my name here, I agree to have my account debited on a monthly schedule if I am a paying member. I will give a minimum of 10 day's notice if I need to cancel or modify my membership at any time.

Today's date:

YYYY

When receipt is confirmed, you will receive the door code for 24-hour access and an email from the director to set up an orientation.

Bank Transfer Authorization Form