NEW SITE - WIM Contact Form

Please fill out the form below.
Red asterisks (*) are the ONLY required fields.
If you are responding about a recent offer, please choose below:

AYP Conference - 3 Months Free Licensing, 2 Free Instructor CertificationsFree To Be Fit - Buy One Program, Get One Free For 6 MonthsSplash Into Summer (25% Off Programming, 3 Free Certifications, 15 Free Aqua Noodles)
Full Name*

First NameLast Name
Cell Phone*
Business Phone
Email*
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Your Role (Check All That Apply)*

Aqua InstructorAqua DirectorLand Fitness InstructorGroup Fitness ManagerWellness / Healthy Living DirectorGeneral ManagerCEOCFOOwnerOther
Your Role (Check All That Apply)*

Aqua InstructorWIM InstructorAqua DirectorGroup Ex InstructorGroup Ex ManagerCEO/OwnerOther
Facility/Club:
Facility/Club Name:*
City:*
State:*
Current WATERinMOTION® Instructor?

YesNo
Group Ex Manager / Healthy Living Director

First NameLast Name
Cell Phone
E-mail
Current WATERinMOTION® Licensee?

YesNo
Are you new to WATERinMOTION®?

YesNo
Aqua Director's Name

First NameLast Name
What WATERinMOTION® Program(s) are you interested in?*

WATERinMOTION® OriginalWATERinMOTION® PlatinumWATERinMOTION® Strength
Aqua Director's Phone
Aqua Director's E-mail
example@example.com
Questions / Comments:
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