First Name: 

 Last Name:

 Address:  

 City:  

 State:  

 Zip Code:  

 Home Phone:

 Work Phone:  

 FAX:  

 E-Mail Address:  

 Employer:  

 Health Insurance Provider :  

 Areas of Interest
 (Check all that apply)  

 Weight Loss
 Weight Gain
 Muscle Strength
 Flexibility
 Cardiovascular Endurance
 Improved Body Composition
 Aerobics
 Step Aerobics
 Calisthenics
 Body Sculpting
 Supervised Training
 Self Defense
 Nutritional Counseling
 Massage
 Physical Therapy
 Chiropractic Care
 Sports Medicine

 Other Interests:

Other interests:

 How many hours do you have to invest
 in a fitness program?

1-3 hours
4-6 hours
7-10 hours
11 hours or more

 How did you hear about us?

Newspaper
Phone Book
Drove By
Member
Friend
T.V.
Radio
Other
      How did you hear about us?