INSURANCE MEMBERSHIP FORM

AMAX FIT

INSURANCE BASED MEMBERSHIP FORM

Please complete the form below to request membership through SilverSneakers®, Renew Active®, One Pass®, or Prime®.
Once submitted, our team will review your information and contact you with next steps.

INSURANCE BASED MEMBERSHIP FORM

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone Number

Date of Birth

Enter your Member ID or Code