Join the AI Wellness Center of Excellence – Membership & Endorsement
Personal and Professional Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Organization/Affiliation
*
Professional Title/Role
*
Profile Picture Upload
Browse Files
Drag and drop files here
Choose a file
Upload a professional image to accompany your avatar profile in our system.
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Membership Selection
Membership Level
*
Founding Membership – One-time offer for the first 100 avatars
Regular Membership (if the Founding Membership is full)
Additional Packages
Event Package – Digital screens tailored for conferences
Clinic Package – Educational screens for clinic spaces and kiosks
Integration Package – Seamless integration with booking and payment processing systems
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Discount Code
If applicable, enter your promo code here.
I would like to opt for recurring payments (monthly or annual)
Agree
Digital Avatar Endorsement
Endorsement Script Submission
*
We’d love to feature your endorsement for AI Wellness and your digital avatar experience. Please provide a short script below, and we’ll handle the rest! (This will be shared on our social media, digital screens at LeadHer Summit, and more.)
Optional Video Upload
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Upload a brief video if you’d prefer to submit your endorsement as a video testimonial.
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Preferred Social Media Handles for Tagging
*
Facebook
Instagram
LinkedIn
Twitter/X
I give permission for AI Wellness to use my endorsement on social media, event screens, and other promotional materials.
*
Yes
No
Wellness Services & Additional Benefits
Would you like to receive information on exclusive wellness services available at discounted rates?
*
Yes
No
Preferred Wellness Services
*
Skincare & Aesthetics
Fitness & Health Coaching
Nutrition Counseling
Other
Choose your preferred location(s) for wellness services if available.
I would like to take advantage of the limited-time bonus offer and receive the AIW Wellness Smart Ring with my membership.
Agree
Select your ring size (available sizes 6-12)
Please Select
Size 6
Size 7
Size 8
Size 9
Size 10
Size 11
Size 12
Payment & Confirmation
Payment Method
Credit Card
PayPal
Other
I agree to the terms and conditions of the AI Wellness Center of Excellence membership and understand that my membership will be activated upon payment.
*
Agree
Final Comments or Questions
Let us know if you have any further questions, requests, or special notes about your membership.
How did you hear about the AI Wellness Center of Excellence?
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