First Name:
Middle Initial:
Last Name:
Street Address:
Address (cont.):
City:
State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip/Postal Code:
Country:
Work Phone:
Home Phone:
E-mail:
What is your age?
Gender:		Male  Female

What is your area of interest or goal?

Please describe how our fitness staff can help you?

How will you reward yourself when you reach your goal?

What types of exercise, sport skill or recreation are you interested in?

What would you like to do (something you have always wanted to do or used to do in the past) as a result of your training?

What is your preferred time slot for exercise?

Do you have any health condition or injury that makes exercising difficult?

What clubs or associations do you belong to?