GROUP CLASS REGISTRATION

GROUP CLASS REGISTRATION
Member Information
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone *

Area CodePhone Number
E-mail*
Parent/Guardian Information (If the participant is under 18 years of age)
Name

First NameLast Name
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone*

Area CodePhone Number
Is the member using any prescribed medication, an inhaler or both? If yes, please explain any instructions.*
Does the member have any allergies, chronic illness, or medical conditions? If yes, please describe.*

MEMBERSHIPS*

Small Group Class($99.00 for each month)

30 days introductory promotional deal. One redemption per new customer. Promotional deal of $99/month. Program includes: unlimited classes, nutrition plan, and a 3d body composition scan. Class times: Mondays, Tuesdays & Thursdays @ 6am, 7am, 9am, 12pm & 730pm. Fridays @ 12pm. Requests can be made for alternative class times.

Group Class($49.00 for each month)

30 days introductory promotional deal. One redemption per new customer. Promotional deal of $49/month. Program includes: unlimited classes, nutrition plan, and a 3d body composition scan. Class times: Tuesday and Thursday @ 9am - 10am / 10:30am - 11:30am

Payment Information
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

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