Member(s): $  + $ 20.00 (One time) Enrollment Fee = $

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Members also receive preferred pricing on up to 5 Fitbit devices!

 

Member Details

First Name *
Middle Initial
Last Name *
Home Phone
Work Phone
Coverage *
Date of Birth *
Gender *
Email *

Address Details

Address Line 1 *
Address Line 2
City *
State *
Zip *

Payment information

Credit Card Number *
Name on Card*
Expiration Date (MM/YYYY)*
CVC (Security Code)*
Credit Card Billing Statement Address Line 1*
Address Line 2
City*
State*
Zip*

Account information

User ID *
Password *