Get Some Moxie		 Get Some Moxie
The Virtual Health Club for People with Developmental Disabilities

Complete the information below and click “Submit” to sign up.
Questions: Moxie@eMainstay.com


 
Agency Name  
Total Number of Group Homes Overall Supported by Agency  
Agency Street Address  
City  
State  
Zip  
Name of Person
Completing Sign Up		  
Title of Person
Completing Sign Up		  
Email Address of Person
Completing Sign Up		  
Phone Number of Person
Completing Sign Up		  
Contact Person for Moxie Health Club Membership Information within Agency
(if same as person completing sign up, indicate “same”)		  
Title of Contact Person  
Email Address of Contact Person  
Phone Number of Contact Person  
Please indicate payment type   Credit Card Auto Debit
We will phone you to get this secure information upon receipt of this sign up form. We will automatically debit your designated bank account, or charge your credit card each month.
   
Memberships start on the 1st of the month and payment is collected on the 1st of each month. Minimum membership term is 6 months. Once we process your sign up, we will confirm your order and provide specifics about accessing your health club benefits.

You just got some Moxie!
Thank you, and congratulations on choosing this first step to change—to live life to its fullest.
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