First & Last Name

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?

2 visits per week 3 visits per week 4 visits per week 5 visits per week 6 visits per week 7 visits per week

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:

1   2   3   4   5   6   7   8   9   10

1   2   3   4   5   6   7   8   9   10

1   2   3   4   5   6   7   8   9   10

1   2   3   4   5   6   7   8   9   10

1   2   3   4   5   6   7   8   9   10

1   2   3   4   5   6   7   8   9   10

Shower Facilities

1   2   3   4   5   6   7   8   9   10