First & Last Name  
Address  
   
City  
State  
Zip Code  
     
Email Address  
Daytime Phone  
Evening Phone  
     

Name of Friends/Family You Would Like To Get Fit With:

 
How much time will you be devoting to a healthier lifestyle per week?
 
Are you willing to forego the cost of a cup of coffee, soda or a candy
bar on a daily basis to fund your healthier body?
Yes    No
 
Is your spouse supportive of your desire to improve your well being?
Yes    No
 
Would an improvement in your health affect your family?

Yes    No
If yes, how? 

 
What was the last thing you have done for yourself?
 
What areas of your body would you like to focus on?
Waist   Hips   Thighs   Chest   Arms   Glutes
 
On a scale from 1 to 10 (10 being most important), please rate the following:
Safety     1   2   3   4   5   6   7   8   9   10
24 hr Access    1   2   3   4   5   6   7   8   9   10
Sunday Access    1   2   3   4   5   6   7   8   9   10
Tanning     1   2   3   4   5   6   7   8   9   10
New Equipment   1   2   3   4   5   6   7   8   9   10
Personal Trainer     1   2   3   4   5   6   7   8   9   10

Shower Facilities

   1   2   3   4   5   6   7   8   9   10

Anytime Fitness Hamburg New York
3701 McKinley Parkway - Suite 1390
Hamburg, New York 14127
Enter McKinley Mall off of Milestrip Road
We are on the left.
Phone: 716.824.4444
Email: hamburgNY@AnytimeFitness.com