Membership Insurance / Usage Request Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Please complete the following form for a receipt of Membership dues paid and for a usage report to be emailed to the address provided below. If a hard copy is required please indicate in the space below. We will have your information sent to you or left at the front desk within 48 hours. First Name * Last Name * Phone * Email * Membership Usage Report Required (Check Here) Membership Payment Receipt Required (Check Here) Usage Report Start Date: Usage Report End Date: Agreement * Confirmation * By checking this box I am stating that I have read and understand how Mitch's Market Street Gym's Insurance Receipt Request process works.